tag:theconversation.com,2011:/us/topics/gp-3821/articlesGP – The Conversation2024-03-06T17:15:01Ztag:theconversation.com,2011:article/2244272024-03-06T17:15:01Z2024-03-06T17:15:01ZGeneral practice is in crisis in the UK – and it’s failing the people who need it most<figure><img src="https://images.theconversation.com/files/579216/original/file-20240301-28-25c0vz.jpg?ixlib=rb-1.1.0&rect=14%2C22%2C4969%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-giving-checkup-woman-exam-room-14464498">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>There is <a href="https://www.bmj.com/content/381/bmj.p966">no doubt</a> that <a href="https://www.theguardian.com/society/2022/nov/20/gps-in-england-treat-up-to-three-times-more-patients-than-safety-limit-demands">primary care</a> in the UK – the services that provide the first point of contact in the healthcare system, such as general practice – isn’t working.</p>
<p><a href="https://www.telegraph.co.uk/news/2023/11/12/gps-elusive-species-elderly-patients-phone-appointments/">Patients report</a> <a href="https://inews.co.uk/news/health/patients-struggle-gp-appointments-collapse-nhs-1742850">difficulties in making appointments</a> and seeing the same GP. <a href="https://www.rcgp.org.uk/getmedia/11f26527-5d11-47f2-a593-1a894c2fff1b/Continuity-of-care-in-modern-day-general-practice1.pdf">Continuity of care</a> is an important factor in patient outcomes, particularly for older adults with comorbidities – those living with more than one long-term condition, such as diabetes or asthma. </p>
<p><a href="https://www.telegraph.co.uk/news/2024/02/23/seeing-the-same-gp-fewer-visits-to-the-doctor/#:%7E:text=Patients%20who%20see%20the%20same,to%20return%20after%20shorter%20periods.">Research shows</a> that patients who see the same doctor have fewer hospital admissions and lower mortality rates. However, we also know that <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">people on the lowest incomes</a> have much more difficulty getting GP appointments. And when they do, they are much more likely to have a <a href="https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/what-are-healthcare-inequalities/deprivation/">much worse experience</a> than those who’re more financially comfortable. </p>
<p>Evidence shows that, in particular, older adults who live in poorer areas <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839575/">struggle to access</a> the primary care that they need. They already have poorer health outcomes, and their life expectancy is lower those living in more affluent areas – yet GP services are not providing the help they should.</p>
<p>Access to <a href="https://www.bmj.com/content/375/bmj.n2916/rr">general practice is vital</a> to maintaining good public health. It’s the entry point to the national health care system, and <a href="https://blogs.bmj.com/bmj/2021/05/14/if-general-practice-fails-the-nhs-fails/">accounts for around 90%</a> of all patient contact with the NHS. </p>
<p>But overall patient satisfaction with general practice <a href="https://www.bmj.com/content/378/bmj.o1764">seems to be in sharp decline</a>. Between 2021 and 2023, the percentage of patients <a href="https://www.kingsfund.org.uk/insight-and-analysis/reports/public-satisfaction-nhs-and-social-care-2022#key-findings">reporting a good overall experience</a> fell from <a href="https://www.england.nhs.uk/statistics/2023/07/13/gp-patient-survey-2023/">71% to 55%</a>. </p>
<p>The reasons for this apparent <a href="https://bmjopen.bmj.com/content/9/2/e026048">crisis in confidence</a> have been covered widely in the media. But reports have tended to focus on GPs rather than the patients who’re most affected. </p>
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<p>For example, it’s been widely reported that the <a href="https://www.rcgp.org.uk/getmedia/155e72a9-47b9-4fdd-a322-efc7d2c1deb4/retaining-gp-workforce-report.pdf">number of GPs</a> <a href="https://researchbriefings.files.parliament.uk/documents/CBP-9731/CBP-9731.pdf">has fallen 4%-5%</a> in recent years and <a href="https://bjgplife.com/stressed-overworked-and-dissatisfied-the-unholy-trio-of-general-practice-in-the-uk/">many doctors</a> who remain in general practice report <a href="https://www.health.org.uk/publications/reports/stressed-and-overworked">feeling stressed and over-worked</a>. It’s no wonder, then, that a significant proportion of <a href="https://www.gponline.com/half-gps-cut-working-hours-ease-workload-poll-shows/article/1811685">GPs have opted to reduce</a> their hours.</p>
<p>There <a href="https://publications.parliament.uk/pa/cm5803/cmselect/cmhealth/113/summary.html">aren’t enough</a> general practitioners <a href="https://www.theguardian.com/commentisfree/2022/jul/03/the-observer-view-on-britain-gp-shortage">to meet growing demand</a>, especially for the <a href="https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf">complex needs of an aging population</a>.</p>
<p>But what of the people disproportionately affected by the crisis in general practice? </p>
<h2>Older, impoverished adults disproportionately affected</h2>
<p>As life expectancy in the <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-expectancy-england">UK increases</a>, the <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/improving-care-for-older-people/">role of general practice</a> in keeping people well and living independently <a href="https://www.msdmanuals.com/home/older-people%E2%80%99s-health-issues/providing-care-to-older-people/continuity-of-care">is crucial</a>. This is particularly true in older patients with comorbidities. The often complex nature of their conditions means that these patients need regular monitoring and access to GP services. </p>
<p>In addition, older adults with comorbidities are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9385725/">often socially isolated</a>, and the human contact provided by the therapeutic relationship developed through regular appointments is <a href="https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1189-9">considered vital</a> to their wellbeing. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853241/">Research has highlighted</a> that the <a href="https://www.health.org.uk/publications/long-reads/measuring-continuity-of-care-in-general-practice">ongoing relationship</a> between GP and patient is particularly important in this group of patients. </p>
<p>However, the <a href="https://www.qmul.ac.uk/media/news/2022/smd/seeing-the-same-gp-is-good-for-your-health-but-only-half-of-patients-are-able-to-do-so.html">continuity of care</a> traditionally provided by the family doctor has declined as primary care struggles to meet the demands placed upon it. In these situations, the influence of <a href="https://patient.info/doctor/health-and-social-class">education and social class</a> on health becomes increasingly apparent. </p>
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<p>A 2024 survey by NHS watchdog <a href="https://www.healthwatch.co.uk/what-we-do">Healthwatch</a> found that already well established links between poverty and ill health are exacerbated by barriers to obtaining healthcare. </p>
<p>The report, which surveyed a representative sample of the population – 2,018 people aged over-16 in England – found that those in poverty were twice as likely to experience problems getting to see a GP than those who identified as “very comfortable” financially. </p>
<p>Louise Ansari, Healthwatch’s chief executive, suggested that the <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">survey’s findings</a> were a warning that the NHS could be moving toward a <a href="https://www.telegraph.co.uk/news/2023/10/20/nhs-care-quality-commission-report-health-service/">“two-tier service”</a> with ease of access closely related to wealth. </p>
<p>Ansari’s concerns seem to be well-founded. In more affluent, middle class areas, the quality of general practice is often better and <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/articles/trendsinpatienttostaffnumbersatgppracticesinengland/2022">more readily available</a>, often because practices have fewer patients. </p>
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<p>Wealthier areas tend to have <a href="https://www.ons.gov.uk/visualisations/censusworkforcequalifications/">more highly educated populations</a>, who tend to be more confident in requesting appointments and articulating their health concerns. </p>
<p>Conversely, people living in <a href="https://theconversation.com/gp-crisis-how-did-things-go-so-wrong-and-what-needs-to-change-208197">less affluent areas</a> with greater levels of deprivation may not always be aware of what they are entitled to, or how to get it. </p>
<h2>Delays in seeking help</h2>
<p>The move to remote consultations is another aspect of the barriers to access faced by those who’re most socially and financially disadvantaged.</p>
<p>While remote consultation <a href="https://bmjopen.bmj.com/content/13/5/e070923">may be appropriate</a> and perfectly satisfactory, even preferable, for many patients, there are people – often from the <a href="https://digitalpovertyalliance.org/uk-digital-poverty-evidence-review-2022/introduction-myths-and-shifts/">most deprived groups</a> – who are <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/exclusion-inclusion-digital-health-care#:%7E:text=Groups%20commonly%20considered%20digitally%20excluded,areas%2C%20people%20from%20low%20socio%2D">digitally excluded</a> (unable to use the internet in ways that are needed to participate fully in modern society) and do not have the resources to access virtual appointments. </p>
<p>But this <a href="https://www.gov.uk/government/news/new-plan-to-make-it-easier-for-patients-to-see-their-gp">lack of easy access</a> for all patients is at odds with public health messaging. </p>
<p>For example, <a href="https://digital.nhs.uk/ndrs/our-work/ncras-work-programme/cancer-awareness-campaigns#:%7E:text=Resources-,Introduction,to%20see%20their%20GP%20sooner">public health campaigns</a> that target older adults, emphasise the importance of early detection of cancer: “<a href="https://www.england.nhs.uk/2022/03/celebrities-join-forces-with-the-nhs-to-encourage-cancer-checks/">if something doesn’t feel quite right … get it checked out”</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/35298272/">Early detection and survival rates</a> in all types of cancer are inextricably linked.</p>
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<p>However, difficulty accessing a GP appointment means that <a href="https://www.bbc.co.uk/news/health-37605573">people are more likely to put off</a> and delay seeking help with their symptoms. The number of <a href="https://www.bmj.com/company/newsroom/every-month-delayed-in-cancer-treatment-can-raise-risk-of-death-by-around-10/">late presentations for cancer</a> in particular means that long term survival rates from cancer are not as good as they should be. </p>
<p>The UK’s ageing population and the recent sharp rise in the cost of living means the number of disadvantaged older people in need of consistent, high quality GP care is rising. But their chance of getting it seems to be ever dwindling.</p><img src="https://counter.theconversation.com/content/224427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Older adults in poorer areas would benefit more from seeing the same GP, but often find continuous primary care harder to access.Robin Lewis, Senior Lecturer in Healthcare, Sheffield Hallam UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2081972023-06-30T10:50:53Z2023-06-30T10:50:53ZGP crisis: how did things go so wrong, and what needs to change?<figure><img src="https://images.theconversation.com/files/534010/original/file-20230626-19-vxau2w.jpg?ixlib=rb-1.1.0&rect=31%2C94%2C2950%2C1800&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many GPs, having fewer opportunities to engage directly with patients has led to a loss of professional satisfaction.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/doctor-checking-patients-blood-pressure-check-2219492231">A.B. Putra/Shutterstock</a></span></figcaption></figure><blockquote>
<p>There has to come a point where doctors decide, I can’t do my job any more – and then the situation will spiral out of control. I would use the term ‘crisis’: so many parts of the NHS are under such enormous pressure that they are unable to provide the personal care that patients need, unable to provide effective care, and increasingly unable to even provide safe care.</p>
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<p>In a speech to mark the 70th anniversary of the founding of the Royal College of General Practitioners, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">reported in the Observer</a>, its outgoing president Martin Marshall was blunt about the state of his profession. His fears for GPs’ futures were echoed across the media throughout the winter of 2022, amid warnings of a “<a href="https://www.pslhub.org/blogs/entry/4267-gps-warn-of-%E2%80%98tsunami-of-demand%E2%80%99-this-winter-as-patient-contacts-surge-200/">tsunami of demand</a>” from the public. In January, a member of the <a href="https://www.generalpracticesurvival.com/">GP Survival</a> network <a href="https://www.theguardian.com/society/2023/jan/24/terrifying-gp-dash-a-and-e-ambulance-delays-nhs-waiting">wrote</a> that the pressures had got too much:</p>
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<p>I’m only 58 but I’m retiring in March. I can’t cope any more with the stress and overtime being a GP involves – doing the job of two people while GPs are criticised regularly by the right-wing media … I am too overloaded and don’t really see the point when my patients are being harmed by delays across the NHS and care services.</p>
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<p>In March, the Health Foundation – one of the UK’s most influential independent health bodies – published a <a href="https://www.health.org.uk/sites/default/files/upload/publications/2023/Stressed%20and%20overworked_WEB.pdf">survey of nearly 10,000 GPs</a> in ten countries around the world. Some 71% of UK GPs said their job was “extremely” or “very stressful” – the highest of the ten countries surveyed, alongside Germany. The report concluded:</p>
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<p>Results from this survey and others show alarming numbers of GPs looking to leave the profession, reduce their hours, or stop seeing patients in the near future … The experience of GPs in the UK should ring alarm bells for government.</p>
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<p>Over the past decade, one in five practices in England and Wales have closed. The multiple challenges facing GPs show no sign of receding, despite the reduced threat posed by COVID. In May 2023, Anita Raja, a West Midlands GP, <a href="https://news.sky.com/story/gps-at-breaking-point-in-englands-most-deprived-areas-12889054">told Sky News</a>:</p>
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<p>GPs are at breaking point. We’re immensely understaffed. Partners are leaving their partnerships, practices are closing down. If it goes on the way it is, we will have no primary care any more.</p>
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<p>For many UK GPs, the seemingly endless demands on their time and “<a href="https://www.pulsetoday.co.uk/news/workload/gps-experience-overwhelming-number-of-daily-patient-contacts-ahead-of-winter/">overwhelming</a>” number of patient contacts are key components of work-related stress. A significant amount of a GP’s day is now spent on clinically-demanding background work, such as making sure that all test results are understood in the context of each patient, and that actions recommended by hospital specialists are appropriately put in place.</p>
<p>“It’s the boiling frog analogy,” Bob Hodges, a Gloucester GP, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">told the Observer</a>. “The water’s not been comfortable for a decade, but it’s now very noticeably warmer. It will soon reach a threshold where there is a collapse.” In the same article, Rowena Christmas, a GP in Monmouthshire, offered this chilling warning:</p>
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<p>I do sometimes feel we are in [the] dark last days of this way of doing things, and it really makes me feel sick to say that … If we lose general practice, we lose the NHS as we know it, with all the awful health inequalities that will follow.</p>
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<h2>The link between stress and GP shortages</h2>
<p>Many GPs say they have <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">long felt undervalued</a> by the general public, the media and the government – with <a href="https://bjgp.org/content/72/725/e907">negative media portrayals</a> of remote GP consultations during the pandemic only adding to these criticisms. Many believe they are being <a href="https://www.bmj.com/content/374/bmj.n2234">blamed for the fallout</a> from more than a decade of underinvestment in primary healthcare.</p>
<p>The increasing levels of <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">work-related stress and low morale</a> is having a damaging effect on <a href="https://prucomm.ac.uk/assets/uploads/Tenth_GPWLS_2019_Final_version_post-review_corrected_1.pdf">recruitment and retention of GPs</a> across the UK. Dissatisfaction with working in the UK is also a factor in some doctors’ decisions to <a href="https://www.gmc-uk.org/-/media/documents/migration-decisions-research-report_pdf-94525731.pdf">take their qualifications overseas</a>.</p>
<p>The Royal College of GPs has predicted a “<a href="https://www.rcgp.org.uk/News/Mass-exodus">mass exodus</a>” of GPs and trainees in the UK over the next few years. Its <a href="https://www.rcgp.org.uk/getmedia/1aeea016-9167-4765-9093-54a8ee8ae188/RCGP-Fit-for-the-Future-A-New-plan-for-General-Practice.pdf">2022 survey</a> of 1,262 GP and trainee respondents in England found that 42% were “likely” to quit the profession within the next five years. One in ten said they expected to leave within a year.</p>
<p>Analysis of the latest <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-march-2023">workforce data</a> confirms a continuing drop in England’s number of GPs – the equivalent of <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis">2,133 fewer fully qualified, full-time GPs</a> than in September 2015. At the same time, GPs’ <a href="https://www.pulsetoday.co.uk/news/workload/gps-working-average-11-hour-day-major-survey-reveals/">working hours have increased</a> and the <a href="https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice">number of appointments delivered</a> in England continues to exceed previous monthly records.</p>
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<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
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<p>Yet difficulties in <a href="https://www.bbc.co.uk/news/health-65275367">accessing NHS GPs</a> – including the infamous “<a href="https://www.itv.com/news/2023-05-08/end-the-8am-scramble-gp-booking-systems-to-be-overhauled-under-new-plans">8am scramble</a>” for on-the-day appointments – remain of major public concern. In 2023, a widely circulated <a href="https://twitter.com/mrdanwalker/status/1591373610085654528">joke</a> suggested trying to buy a ticket for comedian Peter Kay’s latest tour was as hard as getting a GP appointment.</p>
<p>One policy response has been to bring in many <a href="https://www.england.nhs.uk/gp/expanding-our-workforce/">non-GP practitioners</a> to work alongside GPs in their surgeries. However, our <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/YWTU6690/#/abstract">May 2022 study</a> found that the need for GPs to provide ongoing supervision and support for these staff, some of whom have little or no experience of working in general practice, has created a <a href="https://blog.policy.manchester.ac.uk/posts/2021/10/achieving-the-right-mix-of-skills-in-general-practice-its-a-process-not-a-destination/">new and, for many GPs, unexpected workload</a>.</p>
<p>The new <a href="https://www.pulsetoday.co.uk/news/pulse-on-workforce/2-4bn-workforce-plan-to-increase-gp-training-places-by-50-among-other-measures/">NHS Long Term Workforce Plan</a> for England, announced today, promises a 50% increase in the number of GP training places to 6,000 by 2031, with GP trainees due to spend their entire training in general practice. The new plan has been <a href="https://www.england.nhs.uk/2023/06/record-recruitment-and-reform-to-boost-patient-care-under-first-nhs-long-term-workforce-plan/#:%7E:text=%E2%80%9CThe%20NHS%20Long%20Term%20Workforce,patients%20in%20generations%20to%20come.%E2%80%9D">described</a> by Amanda Pritchard, chief-executive of NHS England, as a “once in a generation opportunity to put staffing on a sustainable footing”. Its effectiveness in resolving the crisis in general practice can, in part, be assessed against achieving increases in the number of GPs that previous government pledges have failed to deliver.</p>
<p>In May, health minister Neil O'Brien <a href="https://twitter.com/BBCBreakfast/status/1655829037770584064">told the BBC</a> that “we’ve got 2,000 more doctors working in general practice than we did in 2019 before the pandemic”. But this figure <a href="https://www.bbc.co.uk/news/health-65531758">included trainee GPs</a> – and according to an <a href="https://www.instituteforgovernment.org.uk/performance-tracker-2022-23/general-practice">analysis by the Institute for Government</a>, the qualified GP workforce has gained little from this increase because recently trained GPs are now leaving UK general practice at an unprecedented level. In its <a href="https://www.health.org.uk/sites/default/files/upload/publications/2023/Stressed%20and%20overworked_WEB.pdf">March 2023 report</a>, the Health Foundation concluded that, in England:</p>
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<p>Despite repeated government pledges to increase the number of GPs … shortages are estimated at 4,200 and could grow to 8,800 by 2031 – around one in four projected GP posts.</p>
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<h2>GPs as ‘conductors of the orchestra’</h2>
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<p>You have so little time to develop relationships with people – to get to know them as you could do in the past. That impacts on clinical decision-making as well – as every patient is new. So, you cannot take any risks. (Reflections of a GP and teaching facilitator)</p>
</blockquote>
<p>The GP practice as a continuously available social safety net – a place where doctors have a sense of who you are over a long period – increasingly feels like a thing of the past. In part, this may be a product of changing expectations in this “<a href="https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/realising-digital-first-primary-care.html">digital first</a>” age of convenience. Relationship-based care by GPs with whom you can share the story of your life and that of your loved ones, even tangentially, may not be what young and fit people assume they need any more.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of GP with a member of his surgery." src="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The traditional vision of GPs having a sense of ‘who you are’ over a long period feels increasingly outdated.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/doctor-checks-blood-pressure-elderly-patient-687757363">ArtoPhotoDesigno Studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>In fact, the average age of the UK population is rising, and with it the number of people requiring ongoing care for (often multiple) long-term conditions and increasingly complex care pathways. Yet the work of GPs has become increasingly shaped by requirements to follow standardised care pathways and achieve specific performance targets. This means the GP’s traditional role as “conductor” of the healthcare orchestra – as opposed to merely a “<a href="https://www.bmj.com/content/353/bmj.i2751">gatekeeper</a>” – is increasingly difficult to carry out.</p>
<p>An example of the everyday emergence of nuance and complexity in relationship-based care is illustrated in the following anonymised account of a patient seen by one of this article’s authors (Harm), when he worked as a practising GP:</p>
<blockquote>
<p>Mr Wei, 59 years old and originally from Singapore, visits the surgery to discuss a cough. He is also hoarse. It is summer, and these problems have been going on for six weeks.</p>
<p>Mr Wei has lived in the UK for more than 30 years. For most of his life, he has smoked more than 30 cigarettes a day. He lives alone and works as a chef in a Chinese restaurant. He has to work very hard under less-than-optimal circumstances, and appears socially marginalised.</p>
<p>To the GP, it is not immediately clear what the purpose of Mr Wei’s visit is. He appears reluctant to discuss his symptoms, and says he isn’t worried about his health at all. But medically, the patient qualifies for an urgent ear, nose and throat referral to detect any early cancer, and the GP also suggests a chest X-ray. No abnormalities are found during these subsequent examinations.</p>
<p>A month later, Mr Wei returns to the GP surgery to discuss what next steps could be taken for his cough. But support to quit smoking is not an option, he says, as it helps him with his stress.</p>
<p>The GP explains there are no drugs that really work for cough. Mr Wei says he understands, and that Chinese medicine could not help him either. He says there are many complicated issues in his life, but that he cannot discuss them.</p>
<p>Mr Wei keeps coming back every three weeks over the next several months, usually with a new symptom of potentially significant medical concern, such as unexplained weight loss – another symptom that warrants an urgent referral.</p>
<p>Over the visits, a measure of mutual trust develops between GP and patient. Mr Wei is not looking for referrals, it transpires, but just wants the GP to be aware of each new symptom and take responsibility for them. In his previous clinical practice in the Netherlands, the GP (relying on clinical experience) would have assumed medical responsibility for deciding not to refer the patient in this situation.</p>
<p>However, in the UK, these many encounters play not only into a professional sense of guilt for spending a lot of time with this patient, but also of feeling “policed” – as if under obligation to respond in ways that were neither required nor wanted by the patient. The GP realises that the pervasive NHS “utility thinking”, with its focus on doing rather than listening, has entered his clinical awareness – and indeed, has overtaken it. His conclusion? It is time to stop practising as a GP.</p>
</blockquote>
<p>Today’s GPs face an uphill struggle. Under severe time pressure, they are often unable to integrate the personal (the patient’s life story and relationship with the GP) with the medical (a hi-tech, interventionist approach that demands increasing levels of specialisation). This is how discontinuation and fragmentation win, and how the core value of general practice – connectedness through continuity – has been diminished or lost.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Book cover" src="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=946&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=946&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=946&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1189&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1189&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1189&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>More than half a century on from John Berger’s influential 1967 work <a href="https://www.theguardian.com/books/2015/feb/07/john-sassall-country-doctor-a-fortunate-man-john-berger-jean-mohr">A Fortunate Man</a>, about a country doctor who trained as a surgeon but became a good GP by listening to his patients, we increasingly regard quality of GP care as something quite different. These days, it is contained in data such as: how long patients wait for an appointment, how close their blood pressure or sugar levels are to recommended levels, or how optimised is their medication regimen.</p>
<p>For many GPs, having fewer opportunities to engage directly with patients has led to a loss of professional satisfaction. It is perhaps a symptom of a <a href="https://www.theguardian.com/society/2020/jul/08/trust-in-uk-healthcare-system-seriously-broken-inquiry-finds">loss of trust in medical professionals</a> that their performance has become so heavily measured by adherence to impersonalised rules, guidelines and protocols. This, of course, modifies definitions of what constitutes “good” general practice, and, in the view of many GPs, makes it more difficult for capable and committed professionals to deliver the care that patients want and need.</p>
<p>Once lost, trust and confidence take time to rebuild – or, as the Dutch saying goes, “trust comes on foot and leaves on horseback”. When so much of their effort is being diverted to satisfy intrusive monitoring, many GPs no longer consider themselves fortunate men or women.</p>
<h2>The impact on patients</h2>
<p>Patients are also suffering the ill-effects of the GP workforce crisis. The national <a href="https://www.gp-patient.co.uk/downloads/2022/GPPS_2022_National_report_PUBLIC.pdf">GP patient survey</a> has shown an unprecedented fall in their overall experience of general practice, with patients living in the most deprived areas reporting the least-positive experiences. </p>
<p>GPs themselves often express concern that their workforce pressures and heavy workloads are increasing the <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">risk to patient safety</a> – and, in the event of medical litigation, to their own professional accreditation. In the <a href="https://www.rcgp.org.uk/representing-you/key-statistics-insights">Royal College of GPs’ survey</a>, 65% of respondents said that patient safety is being compromised due to appointments being too short. In May 2023, the college’s incoming chair, Kamila Hawthorne, <a href="https://www.theguardian.com/society/2023/may/07/patients-getting-sicker-as-they-face-long-waits-for-nhs-care-says-top-gp">told the Guardian</a>:</p>
<blockquote>
<p>Patients getting sicker while they are on the waiting list is something GPs see and worry about … It could be someone awaiting a hip or knee replacement – often the waiting times for orthopaedics can be a year or two, so you know it’s going to take ages. They’ll tell you their toilet is upstairs and that to get up there, they’re having to crawl … Or that the pain is coming to the point where they can’t sleep at night. That’s the kind of thing we hear.</p>
</blockquote>
<p>GPs regularly deal with patients frustrated about long-delayed hospital appointments and procedures. Such issues were exacerbated by the pandemic, which also triggered an abrupt change in the way many GP consultations were carried out.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="'Closed' signs on the door of a GP surgery" src="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A GP surgery closed by COVID in 2020.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mansfield-uk-may-9-2020-stop-1745829095">Eddie Jordan Photos/Shutterstock</a></span>
</figcaption>
</figure>
<p>Early in 2020, a rapid switch from in-person to remote consultations was mandated by the UK government as part of efforts to reduce the spread of COVID-19. Initially, this was widely seen as a positive innovation that contributed to both patient and staff safety. However, by 2021, concerns were being <a href="https://bjgp.org/content/71/702/e1">raised in the media</a> about the quality and safety of this “remote consulting” system, as well as the digital inequalities it highlighted among the elderly and most vulnerable.</p>
<p>Numerous analyses of patients’ access to GP appointments continue to emerge. While national data indicates a <a href="https://www.pulsetoday.co.uk/news/workload/gps-provided-two-million-more-appointments-last-month-than-in-march-last-year/">significant increase</a> in the number of appointments (both in-person and remote) being provided, reports suggest that as many as <a href="https://www.newstatesman.com/politics/health/2023/01/quarter-of-patients-forced-into-ae-because-of-gp-waits">a quarter of accident & emergency patients</a> may have gone to hospital because of the length of GP waiting times, and that growing numbers of people are <a href="https://www.theguardian.com/society/2023/may/19/patients-paying-550-an-hour-to-see-private-gps-amid-nhs-frustrations">turning to private GP services</a> “amid frustration at the delays getting an appointment with an NHS family doctor”. According to David Hare, chief-executive of the Independent Healthcare Providers Network: “Private GP services are one of the big growth areas of a burgeoning private healthcare sector.”</p>
<p>In January, GP Jenna Fowler <a href="https://www.theguardian.com/society/2023/jan/29/nhs-workers-reveal-extent-of-workplace-pressures">told the Guardian</a>:</p>
<blockquote>
<p>When I see or speak to a patient for the first time, I often spend the first few minutes explaining the situation or apologising for delays. Unfortunately, patient dissatisfaction has led to increased reports of abuse towards healthcare staff, which is upsetting and demoralising at a time when we are working so hard to do the best we can for our patients.</p>
</blockquote>
<p>Following the death of Gail Milligan, a Surrey GP who took her own life in July 2022, her husband Chris spoke to the healthcare professionals website <a href="https://www.gponline.com/gp-wife-worked-herself-death-%E2%80%93-something-needs-change/article/1802504">GPonline</a> about the need to protect GPs from the extraordinary pressures now being placed on them – including from the public:</p>
<blockquote>
<p>I would really want public opinion to start changing. I understand people being frustrated because they can’t get a doctor’s appointment, but they need to know the real story of what’s going on behind the scenes, and how hard these people are working – that doctors are dying to offer services they know aren’t up to scratch any more.</p>
</blockquote>
<h2>A whole other level of stress</h2>
<blockquote>
<p>Being a GP now is just awful. You are hung out to dry. The risk is all yours … By introducing privatisation at scale, [the chancellor] Jeremy Hunt and his friends are bringing down what is to me a very valuable resource. American companies are now taking over chains of practices. (Reflection of a current GP)</p>
</blockquote>
<p>General practices operate under a nationally-agreed contract between the Department of Health and the British Medical Association (BMA) to deliver comprehensive healthcare to a registered set of patients (with some variations in Scotland, Wales and Northern Ireland). The contract holders – typically, <a href="https://www.bmj.com/careers/article/the-bmj-s-guide-to-gp-partnerships#:%7E:text=A%20GP%20partner%20is%20a,for%20running%20their%20own%20practice.">GP partners</a> – bear responsibility for their practice’s business operations, including the expenses incurred in the employment of staff (clinical, managerial and administrative) and provision of premises.</p>
<p>This partnership model – the main legal structure for general practice since the NHS was established in 1948 – has proved resilient in the face of policy changes, and has successfully adapted in response to changing health priorities. But for the GP partners who make up just over half of all UK GP roles (compared with more than 40% who are in non-partner, employed positions), the relative freedom and opportunities of the partnership model come with a large amount of additional work – and the potential for stress and worry.</p>
<p>Most GP partners operating under this small business model feel far removed from national-level decision-making processes. Yet the business risks, contractual responsibilities and financial pressures they personally hold have increased significantly in recent decades. As Bob Hodges, a Gloucester GP, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">told the Observer</a>:</p>
<blockquote>
<p>There is always the threat in small partnerships of being the last man standing; if you are in a partnership of two and your partner resigns, then you have all the financial liability of an asset you are not allowed to sell.</p>
</blockquote>
<p>Policies introduced by both Conservative and Labour governments have complicated the GP partnership model by focusing on solving particular problems – for example, prioritising speed of access over <a href="https://bjgp.org/content/bjgp/early/2020/08/10/bjgp20X712289.full.pdf">continuity of care</a>, leading to patchwork contractual arrangements and add-on payments. Meanwhile they have failed to resolve key issues such as the shortage of available GP appointments in <a href="https://www.cam.ac.uk/research/news/worsening-gp-shortages-in-disadvantaged-areas-likely-to-widen-health-inequalities#:%7E:text=Areas%20of%20high%20socioeconomic%20disadvantage,at%20the%20University%20of%20Cambridge.">areas of greater social deprivation and poorer health</a>.</p>
<p>The increased requirement for performance monitoring and target-driven performance incentives that accompanied the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585462/">2004 version of the national GP contract</a> have also created much additional work for GP partners, making the prospect of running a sustainable general practice ever-more challenging.</p>
<p>Resources and facilities in many GP surgeries are also sub-standard. More than a third of GP respondents to the <a href="https://www.rcgp.org.uk/getmedia/1aeea016-9167-4765-9093-54a8ee8ae188/RCGP-Fit-for-the-Future-A-New-plan-for-General-Practice.pdf">Royal College of GPs survey</a> said their practice premises are not fit for purpose (38%), and that IT for booking systems are not good enough (34%).</p>
<p>Yet much of this slips under the radar – until, periodically, practices “fail” or <a href="https://www.thewestmorlandgazette.co.uk/news/20603107.gps-run-central-lakes-medical-group-resign-contract/">hand back a contract</a> when they can’t recruit sufficient staff to deliver a safe service.</p>
<p>The precarious financial status of general practice was highlighted during a <a href="https://www.pulsetoday.co.uk/news/politics/general-practice-not-massively-profitable-says-health-minister/?utm_content=buffer9eb55&utm_medium=organic%2520social&utm_source=twitter&utm_campaign=pulsesocial">recent House of Lords debate</a>. Responding to concerns that GP practices were at risk of being bought out by US companies, Nick Markham, a government health minister, <a href="https://www.theyworkforyou.com/lords/?id=2023-06-05a.1120.2&s=GPs#g1120.5">admitted</a> that “it is not a massively profitable area at the moment”.</p>
<p>Meanwhile, data on GP incomes contradicts <a href="https://www.dailymail.co.uk/news/article-9356701/NHS-GP-earning-700-000-year-one-hundreds-earning-Prime-Minister.html">some media suggestions</a> of “fat cat” salaries. When reduced hours and inflation are taken into account, <a href="https://bjgp.org/content/bjgp/70/690/e64.full.pdf">GP income reduced</a> by 10% for partner GPs and by 7% for salaried GPs between 2008 and 2017. In 2022, it was revealed that, despite the Department of Health’s recommendation of a pay rise for general practice staff, there would be <a href="https://www.pulsetoday.co.uk/news/breaking-news/gp-practices-will-not-get-funding-uplift-to-cover-staff-pay-rise-government-confirms/#:%7E:text=The%20five%2Dyear%20GP%20contract,4.5%25%20in%202022%2F23">no adjustment to practice funding</a> to reflect this.</p>
<h2>What can be done to address the GP crisis?</h2>
<blockquote>
<p>The first step to solving a problem is to acknowledge it, and we believe that general practice is in crisis. It is clear from the latest GP patient survey results that, despite the best efforts of GPs, the elastic has snapped after many years of pressure.</p>
</blockquote>
<p>This <a href="https://committees.parliament.uk/publications/30383/documents/176291/default/">Future of General Practice</a> report, compiled by the cross-party <a href="https://committees.parliament.uk/committee/81/health-and-social-care-committee/">Health and Social Care Committee</a> after taking evidence from many sources, went on to conclude that:</p>
<blockquote>
<p>Patients are facing unacceptably poor access to, and experiences of, general practice. Patient safety is at risk from these unsustainable pressures … [But] given their reluctance to acknowledge the crisis in general practice, we are not convinced that the government or NHS England are prepared to address the problems in the service with sufficient urgency.</p>
</blockquote>
<p>As academics working closely with GPs and listening to daily accounts of life on the “frontline”, we do not believe there is a magic solution to the challenges they face – but our research, observations and experience point to three key areas for action.</p>
<p><strong>1. Make general practice a more attractive career</strong></p>
<p>Job satisfaction for GPs is closely linked to having the time and space to <a href="https://bjgp.org/content/66/643/e136">achieve the professional standards they aspire to</a> – placing greater value on responding to the real-life needs of patients such as Mr Wei, than on achievement of incentivised targets that may be poorly aligned with patients’ needs.</p>
<p>While GPs are already distributing elements of their work to other trained staff, many continue to feel overwhelmed by administrative work of low clinical value, and by the volume of work now being <a href="https://academic.oup.com/pmj/article-abstract/98/1161/e14/6959026">transferred to them from other health providers</a>. For example, recommendations designed to reduce requests for GPs to take responsibility for checking patient investigations (rather than the hospital team who originated them) have so far had limited effect.</p>
<p><strong>2. Emphasise the importance of the ‘expert generalist’ role</strong></p>
<p>One of the most prominent policies to address the primary healthcare workforce crisis in England in recent years has been the <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/YWTU6690/#/abstract">recruitment of different types of non-GP practitioner</a>, such as pharmacists, paramedics and physician associates. The idea is that, as less complex casework is diverted away to these other practitioners, GPs are able to spend more time dealing with complex cases.</p>
<p>However, our research shows that GPs’ overall workload and job satisfaction levels <a href="https://evidence.nihr.ac.uk/alert/gps-workload-did-not-improve-when-practices-employed-other-clinicians/">have not improved</a> through implementation of this policy, which also risks reducing the <a href="https://www.bmj.com/content/bmj/356/bmj.j84.full.pdf">continuity of a patient’s care</a>. It is a sticking plaster that cannot seamlessly fill the gaps arising from the GP crisis. </p>
<p>The newly-announced <a href="https://www.england.nhs.uk/2023/06/record-recruitment-and-reform-to-boost-patient-care-under-first-nhs-long-term-workforce-plan/">NHS Long Term Workforce Plan</a> promises ambitious ideas for different approaches to training clinical staff, as well as actions to improve staff retention across the NHS workforce in England. Sustainable work schedules, including adequate time for GPs to provide expert clinical support for colleagues, should be an integral part of this plan. </p>
<p>It is important that all practitioners entering general practice – whatever their specialism – receive training and experience to prepare them for the immense breadth of general practice casework. The importance of the “expert generalist” role must not be lost in any restructuring of the primary care workforce.</p>
<p><strong>3. Give GPs more choice in how to run their practice</strong></p>
<p>In recent years, there has been a gradual reduction in the <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-march-2023">proportion of GPs who work as GP partners</a>. Pointing to this decline, some health commentators suggest this contractual model is <a href="https://www.ft.com/content/8de41b21-1bc1-478d-ad1d-0f010eeb37af?shareType=nongift">no longer the best way to organise general practice</a>. The threatened closure of GP practices has, on occasion, seen community trusts (or other bodies) take over these practices, offering GPs an option to work <a href="https://www.health.org.uk/news-and-comment/blogs/should-nhs-trusts-manage-general-practice">under different contractual conditions</a>.</p>
<p>However, the Royal College of GPs remains positive about the “exceptional” added value brought to general practice by GP partners who, often at personal cost, are committed to supporting their staff and serving their communities. The cost-effectiveness of this contractual model was confirmed by an <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf">independent review of GP partnerships</a> in 2019.</p>
<p>Ultimately, whichever model (or combination of models) is adopted, turning the tide for general practice demands a clearer understanding of the GP’s role and how to support it. This includes motivating and empowering the general public towards healthier lifestyles – and, if capacity and capability of the GP workforce can be increased, rebuilding public confidence in this frontline of healthcare. The situation is critical.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/would-better-buildings-help-fix-the-nhs-the-story-of-britains-hospitals-from-grand-designs-to-counting-the-costs-208090?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Would better buildings help fix the NHS? The story of Britain’s hospitals, from grand designs to counting the costs</a></em></p></li>
<li><p><em><a href="https://theconversation.com/its-like-being-in-a-warzone-aande-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline-194197?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">‘It’s like being in a warzone’ – A&E nurses open up about the emotional cost of working on the NHS frontline</a></em></p></li>
<li><p><em><a href="https://theconversation.com/the-inside-story-of-recovery-how-the-worlds-largest-covid-19-trial-transformed-treatment-and-what-it-could-do-for-other-diseases-184772?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">The inside story of Recovery: how the world’s largest COVID-19 trial transformed treatment – and what it could do for other diseases
</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/208197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon Spooner has received funding across several projects from the National Institute for Health Research (NIHR) and The School for Primary Care Research through the University of Manchester. The views expressed here are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the Health Education England. </span></em></p><p class="fine-print"><em><span>Harm van Marwijk was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Kent, Surrey, Sussex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. </span></em></p><p class="fine-print"><em><span>Imelda Mcdermott receives funding from the National Institute for Health Research (NIHR) and Health Education England (HEE) through the University of Manchester. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the Health Education England. </span></em></p>The new NHS workforce plan for England promises a 50% increase in GP training places by 2031. But the challenges GPs are wrestling with go much deeper.Sharon Spooner, Clinical Lecturer, Division of Population Health, Health Services Research & Primary Care, University of ManchesterHarm van Marwijk, Professor in Primary Care, Brighton and Sussex Medical SchoolImelda Mcdermott, Research Fellow, Division of Population Health, Health Services Research & Primary Care, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2040292023-04-20T20:02:27Z2023-04-20T20:02:27ZIf you live in a bulk-billing ‘desert’ it’s hard to see a doctor for free. Here’s how to fix this<figure><img src="https://images.theconversation.com/files/521979/original/file-20230419-28-a9e1kl.jpg?ixlib=rb-1.1.0&rect=11%2C104%2C7764%2C5024&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-examining-sick-patient-face-mask-1718117674">Shutterstock</a></span></figcaption></figure><p>GP fees are hitting more Australians than they did a few years ago. There’s a lot of talk about a crisis in bulk billing, with many people reporting they’re unable to see a doctor without paying an out-of-pocket fee. </p>
<p>But the biggest, most urgent problem is in the communities where most people pay fees, so called bulk-billing “deserts”. These deserts are more likely in poorer areas, so the people who most need bulk billing are missing out.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1647859792986120193"}"></div></p>
<p>While Medicare funding changes are needed to address this problem, we also need to look at more innovative solutions. One option is for federal and state governments to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> and support or set up clinics that employ doctors, nurses and other health workers. </p>
<h2>Bulk billing is falling, but from a historic high</h2>
<p>The share of patients who <a href="https://www.health.gov.au/resources/publications/medicare-statistics-per-patient-bulk-billing-dashboard-2021-22?language=en">never paid a GP fee fell</a> from 67% in 2020-21 to 64% in 2021-22. But those rates are still high by recent standards. The rate has only fallen back to the level of 2015, and it remains much higher than a decade ago.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Yes, it’s troubling to see bulk billing falling, especially when fees have risen a lot. Patients who are not bulk billed now pay <a href="https://www.health.gov.au/resources/publications/medicare-annual-statistics-state-and-territory-2009-10-to-2021-22?language=en">on average A$45</a> out of pocket when they see a GP. This is up 20% in real terms over the past decade. </p>
<p>But while the national trend is concerning, it masks a much bigger problem.</p>
<h2>Great disparity</h2>
<p>In some parts of Australia – for example, <a href="https://www.theguardian.com/news/datablog/2023/feb/17/revealed-the-areas-where-australians-are-struggling-to-access-free-gp-care">the electorates</a> of Chiefly, Fowler, and Werriwa in outer-western Sydney – more than nine in ten GP patients are always bulk billed. </p>
<p>But in other parts – for example, the electorates of Canberra, and Franklin and Clark in southern Tasmania – that figure is less than four in ten. </p>
<p>Unlike the overall bulk-billing rate, these vast disparities have persisted for many years: the problem was just as bad a decade ago. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Bulk-billing deserts wouldn’t be such a problem if they were only in the wealthiest parts of Australia, because fees are less likely to stop wealthy people getting the care they need. But there are bulk-billing deserts in many poorer areas. </p>
<p>Compared to all but the wealthiest areas, the bottom fifth of electorates by income have the lowest bulk-billing rates. In 13 of the lowest-income electorates, less than 60% of patients are bulk billed. </p>
<p>Rural areas are worse off too: 60% of patients in rural areas are always bulked billed, compared to almost 69% in metropolitan areas.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>The bulk-billing deserts in poorer parts of Australia represent a serious failure of the system. Nationally, about <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">3.5%</a> of people say they skip GP care because of the cost, with higher rates in rural and poorer areas. Those figures will be far higher in bulk-billing deserts, putting many people’s health at risk. </p>
<h2>What the government should do</h2>
<p>There have been <a href="https://www1.racgp.org.au/newsgp/professional/crisis-summit-white-paper-released">calls</a> to pour billions of dollars into increasing the Medicare rebate and bulk billing incentives. </p>
<p>But while the government should make sure payments to GPs keep up with their costs, that won’t fix the problem of bulk-billing deserts. </p>
<p>It might help arrest the decline in bulk billing nationally, and in some areas where bulk billing is low. But the money will mostly flow to high-bulk billing areas – it won’t do much to provide more care where there is far too little. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
</strong>
</em>
</p>
<hr>
<p>Bulk billing deserts are an enduring problem that need new solutions. To turn them around, the government must tackle two of the structural problems causing them: one-size-fits-all funding of GPs, and areas that don’t have enough health care to go around. </p>
<p>The government has already <a href="https://www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf">signalled</a> it will develop a new funding model that pays GPs for providing ongoing care, which would improve on the current <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">outdated and dysfunctional system</a>. That funding should give <a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">higher payments</a> for patients with greater need. </p>
<p>That would boost income for clinics with patients who need free care the most, helping those clinics to avoid charging their patients. It would be a big step in the right direction.</p>
<figure class="align-center ">
<img alt="Clinician checks a patient's blood pressure" src="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Funding reform will help clinics avoid overcharging patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-nurse-measures-blood-pressure-senior-1817431535">Shutterstock</a></span>
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<p>But even then, there would still be areas without enough health-care workers to meet the community’s needs, including many rural areas, resulting in too little care, and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/joie.12098">too little bulk billing</a>. Governments must go well beyond the Medicare rebate and other incentives to fix these broken health-care “markets”. </p>
<p>The federal and state governments need to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> to support existing clinics or set up new ones that employ salaried health-care workers. This support needs to be tailored to local needs. It could be employing a GP to work out of a rural hospital if there are no GPs in the area, or setting up a new <a href="https://treasury.gov.au/sites/default/files/2022-03/258735_national_rural_health_alliance.pdf">community-controlled primary care service</a>, or helping an existing clinic hire extra staff. </p>
<p>Rather than ad hoc announcements, there should be secure national funding for this care, targeted at the areas of greatest need – especially the poorest bulk-billing deserts. </p>
<p>This change should be accompanied by many other reforms to attract clinicians to areas where they’re needed most, such as further expanding new <a href="https://www.abc.net.au/news/2023-04-15/gp-s-idea-for-rural-generalist-hub-to-avoid-doctor-burnout/102102204">models</a> of GP <a href="https://www.mlhd.health.nsw.gov.au/getmedia/0d396ca5-0028-4cca-99ac-e573dd90bda8/A4-Brochure-Rural-Generalist-Training-Pathway">employment</a> and <a href="https://www.abc.net.au/news/2023-01-27/australia-first-trial-to-retain-gps-in-rural-areas/101898362">training</a> in rural areas, which give “<a href="https://www.health.gov.au/our-work/national-rural-generalist-pathway">rural generalist</a>” doctors a single employer during their training across a range of different health settings in a region.</p>
<p>There should also be reforms to expand the teams supporting GPs in areas with too little care. This can reduce GP burnout, allow clinics to provide more care, and bring Australia <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">in line</a> with other countries. As well as administrative, allied health, pharmacist and other roles, some teams could include <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">physician assistants</a>, who work under the supervision of a doctor and can provide the full range of services a doctor provides.</p>
<p>One test for next month’s federal budget is whether it funds solutions to bulk-billing deserts – an enduring injustice in our health-care system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/204029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Lachlan Fox's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>In Australia’s bulk-billing ‘deserts’, it’s incredibly difficult to find a doctor who will bulk bill. The government should step in to support or set up clinics so locals have access to health care.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1995952023-03-08T00:19:08Z2023-03-08T00:19:08ZMy kids are behind with their vaccines. How do they catch up?<figure><img src="https://images.theconversation.com/files/511564/original/file-20230222-20-7ndkjm.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C1000%2C657&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/father-baby-girl-home-sleeping-1069794509">Shutterstock</a></span></figcaption></figure><p>The vast majority of Australian children are up-to-date with their vaccines. But vaccination rates have <a href="https://ncirs.org.au/sites/default/files/2022-12/Coverage%20report%202021%20SUMMARY%20FINAL.pdf">dipped slightly</a> over the past few years.</p>
<p>Fewer health checks, reduced access to routine health care during lockdowns, and fear of COVID have been the <a href="https://www.tandfonline.com/doi/full/10.1080/07853890.2021.2009128">main reasons</a>.</p>
<p>If that’s been the situation for your family, you can still catch up. Here’s how to check which vaccines are due for your children and how to organise appointments.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needles-are-nothing-to-fear-5-steps-to-make-vaccinations-easier-on-your-kids-153639">Needles are nothing to fear: 5 steps to make vaccinations easier on your kids</a>
</strong>
</em>
</p>
<hr>
<h2>Which shots are due?</h2>
<p>If you are unsure which vaccines are given at different ages:</p>
<ul>
<li><p><strong>look up the vaccine schedule</strong>, officially called the National Immunisation Program Schedule. <a href="https://www.health.gov.au/resources/publications/national-immunisation-program-schedule?language=en">This lists</a> the recommended free vaccines at various ages</p></li>
<li><p><strong>download a vaccine scheduling app</strong>. Some states <a href="https://www.health.nsw.gov.au/immunisation/app/Pages/default.aspx">have an app</a> you can download to create a personal vaccine schedule for your children, with reminders of what’s due and when</p></li>
<li><p><strong>chat to your GP</strong>. The next time you see a GP (for any reason), you can ask about vaccines and which ones are due.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-are-you-up-to-date-with-your-vaccinations-116510">Health Check: are you up to date with your vaccinations?</a>
</strong>
</em>
</p>
<hr>
<h2>I think we’re behind. How do I check?</h2>
<p>If you think your child has missed a shot but want to check, obtain your child’s <a href="https://www.servicesaustralia.gov.au/how-to-get-immunisation-history-statement?context=22436">immunisation history statement</a> using:</p>
<ul>
<li><p>your Medicare online account through myGov or</p></li>
<li><p>the Medicare app.</p></li>
</ul>
<p>You can also call the <a href="https://www.health.gov.au/contacts/australian-immunisation-register-contact">Australian Immunisation Register</a> (1800 653 809) and ask for your child’s immunisation history statement to be sent to you. This can take up to 14 days to arrive in the post. </p>
<p>If your child is over the age of 14, they can get their immunisation history statements themselves.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Teenager sitting in front of laptop" src="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some teenagers can access their own immunisation records.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-girls-sitting-stressed-studying-online-2007572123">Shutterstock</a></span>
</figcaption>
</figure>
<p>If you’re not eligible for Medicare, you can still get your immunisation history statement online <a href="https://www.servicesaustralia.gov.au/how-to-get-immunisation-history-statement?context=22436#a2">through myGov</a>. </p>
<p>In very rare cases, a vaccine may have been given but not recorded on the Australian Immunisation Register. </p>
<p>If you think this may be the case, check your child’s baby health book, as information may have been recorded there. You may also need to check with the GP who gave the vaccine. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-vaccinated-at-the-pharmacy-make-sure-its-recorded-properly-140070">Getting vaccinated at the pharmacy? Make sure it's recorded properly</a>
</strong>
</em>
</p>
<hr>
<h2>OK, we are behind. What now?</h2>
<p>If there are no written records available of past vaccination, your child will be offered catch-up vaccines appropriate for their age.</p>
<p>But children who missed their recommended vaccines in childhood can also still receive them free <a href="https://www.health.gov.au/topics/immunisation/immunisation-information-for-health-professionals/catch-up-immunisations#who-can-get-free-catchup-immunisations">before they turn 20</a>. </p>
<p>Depending on the child’s age, you can go to your local doctor, pharmacy, hospital immunisation clinic, local council or see a community health nurse. </p>
<p>Find your local health service <a href="https://www.healthdirect.gov.au/australian-health-services">using this search engine</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-combination-vaccines-dont-overwhelm-kids-immune-systems-82377">No, combination vaccines don't overwhelm kids' immune systems</a>
</strong>
</em>
</p>
<hr>
<h2>I may need an interpreter</h2>
<p>Catch-up vaccinations are free. But we understand that families who speak a language other than English can face challenges navigating the health system, including <a href="https://www.publish.csiro.au/PY/PY10065">accessing vaccines</a>. </p>
<p>If this applies to your family, or someone you know, you or they can use an interpreter to talk to the GP about catch-up vaccinations. </p>
<p>This is a <a href="https://www.tisnational.gov.au/en/Non-English-speakers/Frequently-Asked-Questions">free phone service</a>, covering more than 150 different languages. Call 131 450.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nearly-1-in-4-of-us-arent-native-english-speakers-in-a-health-care-setting-interpreters-are-essential-115125">Nearly 1 in 4 of us aren't native English speakers. In a health-care setting, interpreters are essential</a>
</strong>
</em>
</p>
<hr>
<h2>I have a large family. Any tips?</h2>
<p>If you have multiple children, the GP or practice nurse will tell you how many appointments you will need to ensure your children are up-to-date with their vaccines.</p>
<p>Here are some tips to help things run smoothly:</p>
<ul>
<li><p><strong>bring an extra adult</strong> (if possible) to sit outside the clinic with children not being immunised. This reduces the risk of distractions in the clinic</p></li>
<li><p><strong>try to ring ahead</strong> to let the GP surgery know they need catch-up vaccines. This allows the team time to work out a catch-up schedule</p></li>
<li><p>if you have records of vaccines given overseas speak to the surgery about <strong>dropping records in before</strong> the appointment. Again, this will allow the nurse to work out the catch-up schedule before you arrive</p></li>
<li><p>in some situations, you may be able to have <strong>slightly longer gaps between vaccines</strong> to reduce the number of visits needed. This will depend on the situation. The GP or practice nurse will be able to determine if this is possible based on what vaccines are needed.</p></li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Family with 4 children sitting on sofa" src="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Large family? Ring ahead.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-photo-arab-muslim-family-sitting-2075149054">Shutterstock</a></span>
</figcaption>
</figure>
<h2>How about flu or COVID shots?</h2>
<p>Beyond the vaccines on the National Immunisation Program, some children are also recommended a flu and COVID shot, depending on their age.</p>
<p>Children aged 6 months and older are also recommended to receive a yearly influenza vaccine (free for kids <a href="https://www.health.gov.au/campaigns/influenza-vaccination-for-children-under-5">6 months to under 5 years</a>). If they are <a href="https://www.health.nsw.gov.au/news/Pages/20200316_01.aspx">older than 10 years</a>, they can get this flu vaccine at either a GP clinic or pharmacy. </p>
<p>COVID vaccination is currently recommended for children aged 6 months up to 5 years only if children have <a href="https://www.health.gov.au/news/atagi-recommendations-on-covid-19-vaccine-use-in-children-aged-6-months-to">special medical or other needs</a>, including a very weak immune system, disability, or complex or multiple health conditions. </p>
<p>Most children aged 5-17 years are recommended to have <a href="https://www.health.gov.au/our-work/covid-19-vaccines/who-can-get-vaccinated/children#who-is-eligible">two doses</a> of a COVID vaccine. </p>
<p>If your child has not received a COVID vaccine and you want some help deciding, there’s <a href="https://www.ncirs.org.au/covid-19-decision-aids">online help</a> depending on the age of your child.</p>
<hr>
<p><em>For more information about vaccines and catch-up vaccination, call the <a href="https://www.health.gov.au/contacts/national-immunisation-information-line">National Immunisation Information Line</a> on 1800 671 811. For specific medical advice, see your health-care provider.</em></p><img src="https://counter.theconversation.com/content/199595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Seale is an investigator on research studies funded by NHMRC and has previously received funding for investigator driven research from NHMRC and NSW Ministry of Health, as well as from Sanofi Pasteur, Moderna and Seqirus.</span></em></p><p class="fine-print"><em><span>Abela Mahimbo has previously received funding from GSK for investigator driven research.</span></em></p><p class="fine-print"><em><span>Jane E Frawley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Catch-up vaccinations are free. These hints and tips will help you get started.Holly Seale, Associate professor, UNSW SydneyAbela Mahimbo, Lecturer in Public Health, University of Technology SydneyJane E Frawley, NHMRC Research Fellow, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1996332023-02-24T04:19:31Z2023-02-24T04:19:31ZNHS recovery plan: why an extra £2.6 billion is not enough without more staff<figure><img src="https://images.theconversation.com/files/511633/original/file-20230222-18-5b2d4y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sheffield-uk-57-support-your-nhs-2003568701">Matthew Troke/Shutterstock</a></span></figcaption></figure><p>The UK government has announced an extra £1 billion of funding to support 800 new ambulances, 100 specialist mental health vehicles and 5,000 more sustainable hospital beds. This sum has been ringfenced for 2023-24 to provide extra capacity and support for staff in the urgent and emergency services. Rishi Sunak’s plan also includes £1.6 billion, to be provided up to 2025, for adult social care, and £150 million for building 150 new facilities to support mental health care. </p>
<hr>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/nhs-recovery-plan-why-an-extra-2-6-billion-is-not-enough-without-more-staff-199633&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/us/topics/audio-narrated-99682">here</a>.</em></p>
<hr>
<p>This <a href="https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf">two-year plan</a> comes in response to emergency healthcare in Britain being labelled a “national emergency”. A recent <a href="https://committees.parliament.uk/publications/33569/documents/183655/default/">parliamentary report</a> investigating access to <a href="https://theconversation.com/why-ambulance-workers-in-england-and-wales-are-going-on-strike-196434">emergency services</a> has highlighted the lack of alternatives for emergency 999 calls and broken models of primary and community care.</p>
<p>Recent statistics show that in January 2023, on average <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2023/02/Statistical-commentary-January-2023-cftre1.pdf">72%</a> of patients attending A&E were either admitted, transferred or discharged within four hours. This represents a significant drop from the 95% standard, which was last met in July 2015. The <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">average waiting time</a> for <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-response-times#:%7E:text=Category%202%20ambulance%20calls%20are,from%20sepsis%20or%20major%20burns.">category 2 ambulance calls</a>, meanwhile, is over an hour and a half (93 minutes), against a target of 18 minutes. </p>
<p>The government’s plan seeks to <a href="https://www.england.nhs.uk/2023/01/major-plan-to-recover-urgent-and-emergency-care-services/">improve</a> the four-hour A&E wait performance, bringing it up to 76% of patients by March 2024. It aims to achieve ambulance waiting times of 30 minutes, on average, for category 2 situations over the next year. And it prioritises finding healthcare solutions in the community to free up hospital beds.</p>
<figure class="align-center ">
<img alt="An ambulance outside an A&E department." src="https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One in four paramedics say they would leave the profession if they could.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-june-17th-2020-ambulance-1758285437">Chris Dorney/Shutterstock</a></span>
</figcaption>
</figure>
<p>Research has long shown, though, that the <a href="https://www.nuffieldtrust.org.uk/news-item/crisis-of-health-service-resilience-is-years-in-the-making?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">problems</a> facing the NHS – the extent to which it is “broken” – are far greater. Issues around safety, staffing levels and quality of service over the last months have seen the service compared to a <a href="https://theconversation.com/its-like-being-in-a-warzone-aande-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline-194197">“war zone”</a>. An extra £2.6 billion in funding will not be enough to fix the problem.</p>
<h2>Workforce in crisis</h2>
<p>The <a href="https://www.bbc.co.uk/news/health-64190440">latest figures</a> show that <a href="https://theconversation.com/gp-numbers-continue-to-fall-but-the-uk-isnt-unique-in-losing-family-doctors-198699">the UK</a> has fewer <a href="https://www.bbc.co.uk/news/health-61986441">GPs</a> and <a href="https://nhsproviders.org/resources/briefings/community-network-the-staffing-challenges-facing-community-health-services-and-how-we-can-address-them">nurses</a> than most of its OECD counterparts. </p>
<p>Across the NHS, between July and September 2022, there were about 133,000 <a href="https://www.bbc.co.uk/news/uk-64185316">vacancies</a> for full-time staff. An estimated average of <a href="https://www.nuffieldtrust.org.uk/resource/nursing-strikes-facts-and-figures-on-uk-nursing-staff">17,000</a> nursing posts remain unfilled on any given day. In the year to June 2022, one in nine nurses left active service in England; the <a href="https://www.nuffieldtrust.org.uk/news-item/our-urgent-care-system-needs-long-term-rehabilitation-to-meet-patients-needs?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">turnover rate</a> hit 11.5%. </p>
<p>These nursing shortages are resulting in <a href="https://theconversation.com/nhs-nurses-pressures-taking-toll-on-compassion-and-kindness-our-new-study-shows-84315">massive pressure</a> on the frontline staff. A January 2023 article in the Times quoted the director of the Royal College of Nursing, Patricia Marquis, <a href="https://www.thetimes.co.uk/article/nhs-waiting-times-ambulances-heart-attack-stroke-mn50k7n8z">as saying</a> that what she called “corridor care” now appears to be commonplace: </p>
<blockquote>
<p>Some nurses are being booked to work in hospital corridors, others are being asked to buy Ikea hooks so intravenous drips can be attached to the corridor wall, and some patients are having cardiac arrests because of mistakes made using cumbersome oxygen cylinders to treat them.</p>
</blockquote>
<p>Among paramedics, more are now <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">leaving</a> than are joining, with over one in four saying they would leave if they could. In the <a href="https://nhsproviders.org/media/693328/otdb-nhs-staff-survey-results-2021-final.pdf">2021 NHS Staff Survey</a>, only 20% of ambulance staff said there were enough staff in their organisation for them to do their job properly, compared with 30% in the 2019 survey.</p>
<p>Ambulance staff sickness and absences rates are among the <a href="https://bmjopen.bmj.com/content/11/9/e053885">highest</a> within the NHS. They have <a href="https://www.health.org.uk/publications/long-reads/why-have-ambulance-waiting-times-been-getting-worse">increased</a> from 5% in March 2019 to 9% in March 2022. </p>
<p>And in social care, the numbers are no better. Almost half a million adults were <a href="https://www.bbc.co.uk/news/uk-61413697">waiting</a> for council care services in England in the latter half of 2022, amid a record <a href="https://www.bbc.co.uk/news/uk-63177547">165,000 unfilled care jobs</a>. </p>
<p>For the government’s plan to work, it must increase the size and flexibility of the NHS workforce to bring any meaningful improvement in A&E and ambulance waiting times. This means <a href="https://www.nuffieldtrust.org.uk/news-item/our-urgent-care-system-needs-long-term-rehabilitation-to-meet-patients-needs?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">supporting</a>, protecting and retaining staff. However, it remains unclear how the government’s plan will address the acute staff shortages alone. </p>
<h2>Wider organisational crisis</h2>
<p>Beyond the staffing crisis, the NHS faces other critical systemic issues. The pandemic <a href="https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20210215%20GP%20access%20during%20COVID19%20report%20final_0.pdf">has exacerbated</a> problems in accessing GP services, which has seen <a href="https://www.kingsfund.org.uk/publications/solving-issue-gp-access-2019">more patients</a> attending A&E and calling for ambulances – thereby diminishing these services’ capacity to deal with more serious calls. </p>
<p>Further, there is considerable <a href="https://www.kingsfund.org.uk/projects/quality-cold-climate/reducing-variations">variation</a> in how different trusts deliver healthcare, as well as a <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226835/procurement_development_programme_for_NHS.pdf">lack of standard procedures</a> for how they purchase the products, supplies, equipment and services required to do so.
This both increases costs and reduces productivity. The ten ambulance trusts in England, for example, have <a href="https://www.england.nhs.uk/wp-content/uploads/2019/09/Operational_productivity_and_performance_NHS_Ambulance_Trusts_final.pdf">been shown</a> to be using 32 types of double-crewed ambulances, and no standard list of what they are to carry on board. </p>
<p>Elsewhere, across the ambulance trusts, <a href="https://www.ncbi.nlm.nih.gov/books/NBK506843/">non-conveyance rates</a> (when a 999 call does not result in a patient being taken to a healthcare facility) vary hugely, <a href="https://aace.org.uk/wp-content/uploads/2018/06/VAN-HSDR-report-2018.pdf">between 40% and 68%</a>. This can have significant consequences for patient safety and patient choice, not to mention the cost of additional journeys to A&E and <a href="https://dspace.stir.ac.uk/bitstream/1893/11298/1/Keith%20Colver_Treat%20and%20Refer_%20MPhil%20Thesis_FINAL.pdf">fears of litigation</a> brought against staff by members of the public if adverse events occur.</p>
<p>Poor working conditions are adversely affecting staff morale. Ambulance staff report <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">frustration</a> at their inability to respond to 999 calls – and <a href="https://www.tandfonline.com/doi/abs/10.1080/09540962.2021.1899613?journalCode=rpmm20">serve patients effectively</a> – due to wider NHS and A&E pressures, over which they have little control. Staff are increasingly demoralised, staff sickness absences are growing, and support for their wellbeing <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08729-1#citeas">varies significantly</a> across trusts. </p>
<p>With <a href="https://www.theguardian.com/society/2023/jan/20/nhs-leaders-unite-union-ambulance-strikes-planned">reports</a> of more planned ambulance strikes, things are likely to get worse unless the pay dispute is resolved. However, the timing of the introduction of the <a href="https://bills.parliament.uk/bills/3350">transport strikes (minimum service levels) bill</a> creates doubts about the government’s willingness to negotiate. Some political commentators have <a href="https://www.theguardian.com/commentisfree/2023/jan/15/if-rishi-sunak-doesnt-drop-the-macho-act-were-in-for-a-spring-of-continuing-misery">suggested</a> it could lead to a “spring of continuing misery”. </p>
<p>Current strikes within healthcare have been agreed with minimum staffing levels for “life and limb cover” assured. It is, however, interesting to consider that minimum levels of service are not protected under any law on non-strike days. </p>
<h2>No easy fixes</h2>
<p>The problems the NHS faces have been years in the making. They stem from poor decision-making and a lack of political consensus between the two main parties, as well as what some critics have termed an <a href="https://www.spectator.co.uk/article/how-to-fix-the-nhs/">emotional attachment</a> on the part of some politicians to a free NHS. </p>
<p>Most crucially, the service has faced critical <a href="https://www.theguardian.com/commentisfree/2023/jan/15/lest-we-forget-our-nhs-crisis-is-the-deadly-legacy-of-george-osbornes-austerity">underinvestment</a>.
Recent analysis <a href="https://www.kingsfund.org.uk/projects/positions/nhs-funding">suggests</a> that while the recent budget increases are necessary, systemic challenges (particularly around workforce pressures) are likely to continue, including uncertainty about post-pandemic recovery.</p>
<p>This underinvestment has led to serious infrastructural issues. Hospital roofs <a href="https://www.newcivilengineer.com/latest/nhs-trusts-need-hundreds-of-millions-to-stop-hospitals-ceilings-collapsing-10-10-2022/">are collapsing</a>, with NHS England <a href="https://www.theguardian.com/society/2022/sep/28/nhs-england-hospital-roofs-in-danger-of-collapsing-will-not-be-fixed-until-2035">reportedly</a> admitting that “30 buildings at 20 different hospitals run by 18 individual NHS trusts” have at least one roof built with a type of cheap concrete that has been labelled “a ticking timebomb”. There have also been reports of alarming <a href="https://www.theguardian.com/society/2023/feb/17/nhs-unsafe-sewage-leaks">sewage leaks</a> – 456 in 2022 – on to wards and A&E departments</p>
<p>Elsewhere, the emergency response 111 and <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-response-times">999 call triage</a> systems have been shown to be <a href="https://committees.parliament.uk/writtenevidence/113092/pdf/">risk-averse tools</a>, which often default to sending more patients to hospitals and making more ambulance calls than needed. This only adds to the load on an already overloaded workforce. </p>
<p><a href="https://www.longtermplan.nhs.uk/areas-of-work/digital-transformation/">Digital transformation</a> to increase the range of tools and services is an important NHS priority. However, new calls for a technological revolution are frustrated by a history of <a href="https://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn">abandoned IT systems</a> costing more than £10 billion. This is in addition to <a href="https://ebm.bmj.com/content/23/5/161">challenges</a> posed by the built infrastructure and workforce training needed to make such a transformation happen.</p>
<p>The centralised model on which the NHS is built is not fit for purpose in 2023. Devolved healthcare, wherein individual trusts have greater <a href="https://www.kingsfund.org.uk/blog/2015/11/devolution-silver-bullet-swiss-cheese">autonomy</a> and flexibility, would serve the nation better. </p>
<p>Real progress will depend upon <a href="https://theconversation.com/nhs-plans-to-expand-virtual-wards-but-who-will-staff-them-198843">staff availability</a> in the community and <a href="https://www.nuffieldtrust.org.uk/news-item/social-care-reform-across-the-uk-why-does-it-keep-failing">genuine efforts</a> to reform and integrate health and social care – reforms which have been formulated, but not implemented. </p>
<p>Instead, the current system is complex and fragmented, with individual component institutions having competing proprieties and a <a href="https://www.theguardian.com/society/2023/jan/08/sick-man-of-europe-why-the-crisis-ridden-nhs-is-falling-apart">protectionist</a> approach to budgeting. Ultimately, without consensus between the two main political parties, this cannot be solved. Without answers, £2.6 billion will not be enough.</p><img src="https://counter.theconversation.com/content/199633/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paresh Wankhade is affiliated with Fire Services Research & Training Trust (FSRTT) as a Trustee.</span></em></p>The problems facing the NHS have been years in the making: a result of poor decision-making, lack of political consensus and chronic underinvestment.Paresh Wankhade, Professor of Leadership and Management, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1969432023-02-22T19:04:16Z2023-02-22T19:04:16ZGastro or endometriosis? How your GP discusses uncertainty can harm your health<figure><img src="https://images.theconversation.com/files/507527/original/file-20230201-23-1odtda.jpg?ixlib=rb-1.1.0&rect=2%2C5%2C1914%2C1270&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-suffering-from-a-stomach-pain-lying-down-on-couch-5938365/">Sora Shimazaki/Pexels</a></span></figcaption></figure><p>You wake with stomach pain that worsens during the day and decide to see your doctor. You describe your symptoms and your doctor examines you. Then the doctor says, “From what I hear, I think you could just have a stomach bug. Rest and come back in three days.”</p>
<p>This might be a less definitive answer than you’re after. But doctors can’t always be sure of a diagnosis straight away. As <a href="https://link.springer.com/article/10.1007/s11606-022-07768-y">my review</a> shows, doctors use various ways of communicating such uncertainty.</p>
<p>Sometimes there is a mismatch between what doctors say when they’re uncertain and how patients interpret what they say, which can have harmful consequences.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/missed-something-the-doctor-said-recording-your-appointments-gives-you-a-chance-to-go-back-112302">Missed something the doctor said? Recording your appointments gives you a chance to go back</a>
</strong>
</em>
</p>
<hr>
<h2>Why does uncertainty matter?</h2>
<p>Doctors <a href="https://link.springer.com/article/10.1007/s11606-017-4164-1">cannot always explain</a> what your health problem is or what caused it. Such diagnostic uncertainty is a normal and <a href="https://doi.org/10.1001/jama.2022.2141">ever-present part</a> of the processes leading to a diagnosis. For instance, doctors often have to rule out other possible diagnoses before settling on one that’s most likely.</p>
<p>While doctors ultimately get the diagnosis right <a href="http://dx.doi.org/10.1136/bmjqs-2012-001615">in 85-90%</a> of cases, diagnostic uncertainty can lead to diagnostic delays and is a huge contributor to harmful or even deadly misdiagnoses.</p>
<p>Every year, <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">an estimated</a> 21,000 people are seriously harmed and 2,000-4,000 people die in Australia because their diagnosis was delayed, missed or wrong. That could be because the wrong treatment was provided and caused harm, or the right treatment was not started or given after the condition had already considerably progressed. More than <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">80% of diagnostic errors</a> could have been prevented. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C663&q=45&auto=format&w=1000&fit=clip"><img alt="Doctor with stethoscope around neck talking to patient" src="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C663&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Diagnostic uncertainty is a huge contributor to harmful or even deadly misdiagnoses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/crop-close-woman-doctor-prescribe-treatment-1930965026">Shutterstock</a></span>
</figcaption>
</figure>
<p>Three medical conditions – infections, cancer and major vascular events (such as strokes or heart attacks) – are the so-called “<a href="https://doi.org/10.1515/dx-2019-0019">Big Three</a>” and cause devastating harm if misdiagnosed.</p>
<p>In my review, the top three symptoms – fever, chest pain and abdominal pain – were most often linked to diagnostic uncertainty. In other words, most of us will have had at least one of these very common symptoms and thus been at risk of uncertainty and misdiagnosis.</p>
<p>Some groups are less likely to be diagnosed correctly or without inappropriate delay than others, leading to <a href="https://doi.org/10.1001/jama.2022.7252">diagnostic inequities</a>. This may be the case for <a href="https://www.liebertpub.com/doi/10.1089/whr.2022.0052">women</a>, and other groups marginalised because of their <a href="https://onlinelibrary.wiley.com/doi/10.1111/acem.14142">race or ethnicity</a>, <a href="https://doi.org/10.1016/j.socscimed.2020.113609">sexual orientation or gender identity</a>, or <a href="https://doi.org/10.1001/jama.2022.7252">language proficiency</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-your-doctor-describes-your-medical-condition-can-encourage-you-to-say-yes-to-surgery-when-there-are-other-options-157958">How your doctor describes your medical condition can encourage you to say 'yes' to surgery when there are other options</a>
</strong>
</em>
</p>
<hr>
<h2>How often do you hear ‘I don’t know’?</h2>
<p>My research showed doctors often make diagnostic uncertainty clear to patients by using explicit phrases such as: “I don’t know.”</p>
<p>But doctors can also keep quiet about any uncertainty or signal they’re uncertain in more subtle ways.</p>
<p>When doctors believe patients prefer clear answers, they may only share the most likely diagnosis. They say: “It’s a stomach bug” but leave out, “it could also be constipation, appendicitis or endometriosis”. </p>
<p>Patients leave thinking the doctor is confident about the (potentially correct or incorrect) diagnosis, and remain uninformed about possible other causes. </p>
<p>This can be especially frustrating for patients with chronic symptoms, where such knowledge gaps can lead to lengthy diagnostic delays, as reported for <a href="https://doi.org/10.1016/j.ajog.2018.12.039">endometriosis</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1064608335217942528"}"></div></p>
<p>Subtle ways of communicating uncertainty include hedging with certain words (could, maybe) or using introductory phrases (my guess, I think). Other implicit ways are consulting a colleague or the Internet, or making follow-up appointments.</p>
<p>If patients hear “I think this could be a stomach bug” they may think there’s some uncertainty. But when they hear “come back in three days” the uncertainty may not be so obvious.</p>
<p>Sharing uncertainty implicitly (rather than more directly), can leave patients unaware of new symptoms signalling a dangerous change in their condition.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-10-women-are-affected-by-endometriosis-so-why-does-it-take-so-long-to-diagnose-141803">1 in 10 women are affected by endometriosis. So why does it take so long to diagnose?</a>
</strong>
</em>
</p>
<hr>
<h2>What can you do about it?</h2>
<p><strong>1. Ask about uncertainty</strong></p>
<p>Ask your doctor to share any <a href="http://dx.doi.org/10.1515/dx-2021-0086">uncertainty and other diagnostic reasoning</a>. Ask about alternative diagnoses they’re considering. If you’re armed with such knowledge, you can better engage in your care, for example asking for a review when your symptoms worsen.</p>
<p><strong>2. Manage expectations together</strong></p>
<p>Making a diagnosis can be an evolving process rather than a single event. So ask your doctor to outline the diagnostic process to help manage any <a href="http://dx.doi.org/10.1136/ebm.14.3.66">mismatched expectations</a> about how long it might take, or what might be involved, to reach a diagnosis. Some conditions need time for symptoms to evolve, or further tests to exclude or confirm.</p>
<p><strong>3. Book a long appointment</strong></p>
<p>When we feel sick, we might get anxious or find we experience heightened levels of fear and other emotions. When we hear our doctor isn’t certain about what’s causing our symptoms, we may get even more anxious or fearful.</p>
<p>In these cases, it can take time to discuss uncertainty and to learn about our options. So book a long appointment to give your doctor enough time to explain and for you to ask questions. If you feel you’d like some support, you can ask a close friend or family member to attend the appointment with you and to take notes for you.</p>
<hr>
<p><em>I acknowledge the contribution of patient advocate Jen Morris and GP Marisa Magiros to this article. The systematic review mentioned was co-authored by Maria Dahm, William Cattanach, Maureen Williams, Jocelyne Basseal, Kelly Gleason and Carmel Crock</em>.</p><img src="https://counter.theconversation.com/content/196943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria R. Dahm receives funding from the Australian Research Council and the Society to Improve Diagnosis in Medicine. She is affiliated with the Australian New Zealand affiliate of the Society to Improve Diagnosis in Medicine. </span></em></p>Doctors don’t always tell you they’re unsure what’s behind common symptoms, such as a stomach ache. And that can have serious effects.Maria R. Dahm, ARC DECRA and Senior Research Fellow in Health Communication, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993032023-02-09T19:11:35Z2023-02-09T19:11:35ZNeed a bulk-billing GP? Why throwing more money at Medicare isn’t the answer<figure><img src="https://images.theconversation.com/files/509059/original/file-20230208-19-3507v7.jpg?ixlib=rb-1.1.0&rect=1%2C2%2C997%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-consultant-having-meeting-patient-1993144466">Shutterstock</a></span></figcaption></figure><p>Last financial year, the Australian government <a href="https://budget.gov.au/2022-23-october/content/bp1/download/bp1_2022-23.pdf">spent</a> almost A$29 billion on Medicare. Most was spent on primary care – a patient’s usual first contact with the health system when sick or injured, such as GP, allied health and diagnostic services. Every year, this spending increases.</p>
<p>Yet, many patients are paying more to see their GP, some <a href="https://theconversation.com/rising-out-of-pocket-health-costs-are-a-worry-but-the-major-parties-have-barely-mentioned-it-181595">cannot afford care</a> and emergency departments are <a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">overcrowded with patients</a> who could be treated by a GP.</p>
<p>Last week, the Strengthening Medicare Taskforce released its much-anticipated <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">report</a> on how to improve the primary health-care system. The report provided broad-brush recommendations mostly focused on delivering patient-centred care, supported by better health data and information technology.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1622358000051658753"}"></div></p>
<h2>Medicare is set for an overhaul</h2>
<p>An important subtext of the report is to overhaul Medicare, Australia’s national public health insurance scheme. Medicare pays a proportion of costs for every Australian that receives subsidised primary care services.</p>
<p>There has not been a major reform to Medicare since its introduction in 1984. If successful, reforming Medicare will be the greatest change to primary care in decades. </p>
<p>It will help governments usher in long sought-after integrated care pathways – with patients cared for by a team of health professionals that better meet their needs, especially those with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117605/">chronic conditions</a>.</p>
<p>But let’s not celebrate just yet. Major funding reform is not a given. Health Minister Mark Butler concedes there’s a long road ahead, telling <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/radio-interview-with-minister-butler-and-sabra-lane-abc-am-9-february-2023?language=en">the ABC</a> this week that we’re not going to fix Medicare in one budget.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
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</em>
</p>
<hr>
<h2>A battle looms ahead</h2>
<p>A potential battle between health providers and the Australian government looms on the horizon.</p>
<p>That’s because the most ferocious national health-care debates are often about how GPs should get paid. Medicare needs to pay providers based on patient health outcomes. Some providers, like GPs, may be worse off financially if they perform poorly.</p>
<p>That will be a hard pill to swallow. Pressure from strong lobby groups that represent primary care providers may water down reform. That runs the risk of worsening patient outcomes compared to what could be achieved.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Street signage of bulk-billing medical centre on high street" src="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A bulk-billing GP has become harder to find. So we need widespread reform to improve access to quality, value-for-money care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/melbourne-vicaustraliaoct-9th-2019-sign-bulk-1743252638">Shuang Li/Shutterstock</a></span>
</figcaption>
</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/patient-advocate-or-doctors-union-how-the-ama-flexes-its-political-muscle-60444">Patient advocate or doctors' union? How the AMA flexes its political muscle</a>
</strong>
</em>
</p>
<hr>
<h2>How did we get here?</h2>
<p>Successive governments over the past 30 years have tried to tighten the reins on runaway Medicare spending. Most attempts have failed.</p>
<p>The Hawke government introduced a <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2014/April/GP_co-payment_lessons_from_past">$2.50 co-payment</a> in 1991, which GPs could charge to non-concessional patients when they received bulk-billed services. In 1992, Keating abolished this when he became prime minister. The Abbott government tried to introduce a $7 co-payment in 2014, but <a href="https://www.abc.net.au/news/2015-03-03/timeline-dumped-medicare-co-payment-key-events/6275260">dumped the budget announcement</a> against fierce community opposition in 2015.</p>
<p>The Abbott government did manage to freeze the annual increase in Medicare Benefits Schedule fees (fees doctors are paid to perform certain subsidised services) between 2015 and 2020. This led to fierce opposition from primary care providers.</p>
<p>The Australian Medical Association (AMA) <a href="https://ama.com.au/sites/default/files/documents/Handout%20for%20politicians_MBSIndexation%20Freeze.pdf">suggested</a> this would force GPs to increase co-payments and reduce bulk billing to maintain their business returns. </p>
<p>While co-payments <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2020-21/contents/summary">have increased</a>, annual bulk billing rates have only declined in the past year.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=370&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=370&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=370&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=465&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=465&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=465&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Bulk-billing rates have only declined in the past year.</span>
<span class="attribution"><a class="source" href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/health/primary-and-community-health">Productivity Commission</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
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</em>
</p>
<hr>
<h2>How should we fund primary care?</h2>
<p>It’s clear Medicare is no longer “fit for purpose”. Some patients <a href="https://www.aihw.gov.au/getmedia/f6dfa5f0-1249-4b1e-974a-047795d08223/aihw-mhc-hpf-35-patients-out-of-pocket-spending-Aug-2018.pdf.aspx?inline=true">avoid care</a> because they cannot afford it. Patients with higher incomes, and patients living in more affluent areas, often pay more if not bulk billed, but can access primary care easier.</p>
<p><a href="https://www.ama.com.au/media/medicare-report-encouraging-significantly-more-investment-needed-save-general-practice">Increasing Medicare rebates</a>, as the AMA proposes will not fix those problems. </p>
<p>A financial incentive for providers to deliver care of little value to patients <a href="https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia">will remain</a>. Providers will still be paid regardless of the health outcomes they achieve, and care misaligned with best practice will continue to be funded.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/some-gps-just-keep-their-heads-above-water-other-doctors-businesses-are-more-profitable-than-law-firms-192163">Some GPs just keep their heads above water. Other doctors' businesses are more profitable than law firms</a>
</strong>
</em>
</p>
<hr>
<h2>We need a radical rethink</h2>
<p>A complete rethink of Medicare is required to support the vision presented in the Strengthening Medicare Taskforce report. The Australian government must start now, as the health-care system adjusts to a post-pandemic world.</p>
<p>Reforming Medicare cannot happen in isolation. It must sit within a cohesive national vision and a <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-49-roadmap-towards-scalable-value">ten-year plan for health-care funding reform</a>.</p>
<p>Medicare reform should be accompanied by public hospital funding, private health insurance and co-payment reform – the three other major funding sources for health care – to ensure Medicare does not remain siloed while governments seek to integrate care.</p>
<p>An independent national health payment authority should be developed and tasked with designing and coordinating the implementation of funding reform. This would work closely with state and federal governments, primary health networks and local health networks. </p>
<p>It would also clarify who is responsible for which elements of funding reform and reduce the potential for duplicating efforts across states.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1621331889540808704"}"></div></p>
<h2>We need to do things differently</h2>
<p>Australia could benefit from <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-49-roadmap-towards-scalable-value">payment models</a> being explored internationally. These include funding a pathway of multiple, integrated health providers – let’s say a GP working with a physio and nurse practitioner – to provide cheaper care that improves outcomes.</p>
<p>In such “value-based” payment models, there’s an incentive to improve health outcomes and reduce costs. Providers share the cost savings compared to what it would have cost using the current Medicare Benefits Schedule.</p>
<p>If we’re to reform Medicare towards paying for value, then we’ll need much more data on patient health outcomes, other factors that impact health outcomes but are outside the control of providers (such as socioeconomic factors), and data on the cost of delivering care. </p>
<p>That requires reforming the way data is collected and shared, and investment in better information technology infrastructure. </p>
<p>The government will need to work closely with providers to ensure they are equipped to manage the transition towards value-based payment models. It will also need to help providers connect and work together to coordinate different types of care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-the-training-to-diagnose-test-prescribe-and-discharge-nurse-practitioners-could-help-rescue-rural-health-199287">With the training to diagnose, test, prescribe and discharge, nurse practitioners could help rescue rural health</a>
</strong>
</em>
</p>
<hr>
<p><em>Update: the article has been updated to more accurately reflect government expenditure on Medicare.</em></p><img src="https://counter.theconversation.com/content/199303/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Cutler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medicare needs an overhaul to improve patients’ access to quality care. And we have a unique opportunity to shake up how health care is provided.Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992842023-02-09T06:21:56Z2023-02-09T06:21:56Z6 reasons why it’s so hard to see a GP<figure><img src="https://images.theconversation.com/files/509075/original/file-20230209-27-pnpjpj.jpg?ixlib=rb-1.1.0&rect=8%2C179%2C5982%2C3808&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.abc.net.au/news/2021-07-12/remote-nt-gp-shortage-but-new-menzies-research-offers-solutions/100282786">Shutterstock</a></span></figcaption></figure><p>The recently released Strengthening Medicare Taskforce <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">report</a> found more people are <a href="https://www.abc.net.au/news/2023-02-02/australians-delaying-health-care-because-of-cost/101916104">delaying care</a> or attending emergency departments because they can’t get in to see a GP.</p>
<p>And it’s likely to get worse. General practice is shrinking rapidly, with estimates Australia will be <a href="https://www2.deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-cornerstone-health-gp-workforce-06052022.pdf">11,500 GPs short</a> by 2032. This is one-third of the current GP workforce. </p>
<p>So why is it harder to access and afford GP care? Here are six key reasons why.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
</strong>
</em>
</p>
<hr>
<h2>1) Patients are older and sicker</h2>
<p>The population is ageing, and more people with multiple <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview">chronic diseases</a> – such as cancer, diabetes and heart disease – are living longer in the community. Rates of mental illness are <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health">also rising</a>. </p>
<p>This not only increases GPs’ <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00520-9">clinical workload</a>, it also shifts a greater load of <a href="https://www.healthed.com.au/clinical_articles/most-gps-do-3-hours-of-unpaid-work-a-week/">care coordination</a> onto the GP. This decreases the number of patients a GP can see. </p>
<p>GPs have also been under increasing pressure from <a href="https://www1.racgp.org.au/newsgp/professional/female-gps-more-likely-to-spend-time-on-non-billab">administrative</a> and <a href="https://www1.racgp.org.au/newsgp/professional/nudge-letters-in-spotlight-amid-gp-push-back-on-co">compliance</a> activities for Medicare, as well as paperwork for the aged care, disability, social security, health and workplace sectors. </p>
<figure class="align-center ">
<img alt="GP talks to older patient" src="https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients have increasingly complex health issues, which take up more time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-patient-having-consultation-nurse-office-317588417">Shutterstock</a></span>
</figcaption>
</figure>
<h2>2) General practice is no longer financially viable</h2>
<p>GP clinics are less financially viable than they used to be. One <a href="https://www.racgp.org.au/general-practice-health-of-the-nation-2022#:%7E:text=The%202022%20General%20Practice%3A%20Health,the%20provision%20of%20patient%20care">survey</a> of doctors found 48% of respondents said their practices were no longer financially sustainable. As a result, many are closing. </p>
<p>The Medicare rebate has <a href="https://www1.racgp.org.au/newsgp/professional/should-bulk-billing-rates-be-used-as-a-measure-of">increased much more slowly than inflation</a> and was <a href="https://theconversation.com/what-is-the-medicare-rebate-freeze-and-what-does-it-mean-for-you-114169">frozen</a> from 2014 to 2020. </p>
<p>While this was a <a href="https://www.ama.com.au/sites/default/files/2022-11/AMA%27s-plan-to-Modernise-Medicare-Why-Medicare-indexation-matters.pdf">huge saving</a> for the government, a low rebate meant the gap between the cost of care and the rebate had to be passed on to GPs and their patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-medicare-rebate-freeze-and-what-does-it-mean-for-you-114169">What is the Medicare rebate freeze and what does it mean for you?</a>
</strong>
</em>
</p>
<hr>
<p>A GP’s fee has to cover the costs of the whole practice. There are <a href="https://www1.racgp.org.au/newsgp/professional/miserly-mbs-indexation-criticised">growing operating costs</a> for insurance, rent, wages, information technology and consumables like gowns, gloves and single-use clinical equipment. When a GP bulk bills, their businesses <a href="https://theconversation.com/gps-are-abandoning-bulk-billing-what-does-this-mean-for-affordable-family-medical-care-182666">absorb the gap</a> between the cost of care and the Medicare rebate. The rebate is now so low (for example, the <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=2713">rebate</a> for a 45 minute consultation for mental health is A$76), and costs are high, few GPs are able to afford to bulk bill patients. This means people on low incomes have trouble affording the care they need. </p>
<p><a href="https://insightplus.mja.com.au/2022/37/the-harsh-realities-of-working-as-a-female-gp/">Women doctors</a> in particular feel these cost pressures. Medicare rebates are lower per minute for <a href="https://www.smh.com.au/politics/federal/gps-warn-of-higher-fees-without-increased-medicare-rebates-for-long-consults-20220112-p59nqg.html">long consultations</a> and female GPs see more patients with <a href="https://www.smh.com.au/lifestyle/health-and-wellness/we-re-paid-less-to-do-so-much-more-one-female-doctor-speaks-out-20190709-p525lj.html">mental ill-health and complex chronic disease</a> requiring longer appointment times. This leaves women <a href="https://data.gov.au/data/dataset/taxation-statistics-2019-20/resource/0ea4e23c-4462-4fe2-a4b7-339d129c5ede?inner_span=True">GPs earning at least 20% less</a> than their male colleagues. </p>
<figure class="align-center ">
<img alt="Doctor talks on the phone" src="https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women doctors spend more time with patients and earn less.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/doctor-talking-on-the-cellphone-5207089/">Pexels Karolina Grabowska</a></span>
</figcaption>
</figure>
<h2>3) GPs, like other health workers, are becoming unwell</h2>
<p>The rate of <a href="https://www.abc.net.au/news/2021-09-25/doctor-burnout-crisis-looming-warns-psychologist/100449906">physical and mental illness among GPs</a> <a href="https://www.publish.csiro.au/py/fulltext/PY21308">is rising</a>. The causes are complex, and include the <a href="https://www.smh.com.au/national/i-m-totally-utterly-done-the-insider-take-on-our-growing-gp-crisis-20220628-p5axab.html">stress</a> of increasing workloads, <a href="https://www1.racgp.org.au/newsgp/professional/we-need-to-be-kind-to-ourselves-vicarious-trauma-a">vicarious trauma</a> (the cumulative effects of exposure to traumatic events and stories), <a href="https://www.mja.com.au/journal/2016/205/2/estimating-non-billable-time-australian-general-practice">administrative overload</a> and financial worries. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1555696592212090880"}"></div></p>
<p>The suicide rate for female doctors is <a href="https://www.mja.com.au/journal/2018/reducing-risk-suicide-medical-profession">more than twice the national average</a>, and rates of depression <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13717">are high</a>. It can be difficult for doctors to access care, particularly if they work in rural practice.</p>
<p>Abuse and violence is also more common, with one survey finding at least <a href="https://www.racgp.org.au/getmedia/6d67fbc5-6257-4b14-b6b2-639d13264e55/Health-of-the-Nation-2017-report.pdf.aspx">80% of GPs saw or experienced</a> a form of violence at their place of work. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-so-many-gps-leaving-the-profession-how-can-i-find-a-new-one-190666">With so many GPs leaving the profession, how can I find a new one?</a>
</strong>
</em>
</p>
<hr>
<p>However, it is the <a href="https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/">moral distress</a> of knowing how to help patients, but being unable to do so, that often damages their health the most. </p>
<figure class="align-center ">
<img alt="Older doctor treats older patient" src="https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Illness among GPs is rising.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-patient-having-medical-exam-doctor-317585774">Shutterstock</a></span>
</figcaption>
</figure>
<h2>4) Fewer junior doctors are choosing general practice</h2>
<p>Around 40% of junior doctors <a href="https://www.smh.com.au/politics/federal/why-has-my-doctor-stopped-bulk-billing-the-medicare-overhaul-explained-20230130-p5cgj1.html">used to choose general practice as a career</a>. It is now <a href="https://www.racgp.org.au/health-of-the-nation/chapter-5-the-future-of-the-gp-workforce/5-1-interest-in-entering-general-practice-training">15%</a>.</p>
<p>Junior doctors now carry more than <a href="https://insightplus.mja.com.au/2022/1/exorbitant-fees-deter-graduates-from-specialising-as-gps/">A$100,000 in HECS debts</a>, so it is understandable they may <a href="https://www.abc.net.au/news/2022-08-31/gp-shortage-to-worsen-as-junior-doctors-turn-to-specialty-fields/101386674">choose other specialties</a> with similar lengths of training that will earn them <a href="https://data.gov.au/data/dataset/taxation-statistics-2019-20/resource/0ea4e23c-4462-4fe2-a4b7-339d129c5ede?inner_span=True">double or triple the yearly income</a>. </p>
<p>However, we suspect one of the key reasons <a href="https://insightplus.mja.com.au/2019/14/a-students-eye-view-of-the-training-crisis/">junior doctors avoid general practice</a> is the <a href="https://medicalrepublic.com.au/med-school-gp-bashing-has-workforce-consequences/75680">denigration of GPs</a>. GPs are portrayed as <a href="https://www1.racgp.org.au/newsgp/gp-opinion/gps-are-not-self-serving-we-are-desperate">greedy</a>, <a href="https://www1.racgp.org.au/newsgp/professional/gps-forced-to-defend-commitment-to-hippocratic-oat">unethical</a> and <a href="https://medicalrepublic.com.au/down-with-generalist-gatekeepers/74863">incompetent</a>.</p>
<p>We cannot attract young doctors to a profession that is constantly under <a href="https://insightplus.mja.com.au/2022/41/are-doctors-really-parasites-healthcare-system/">public and political attack</a>. Education Minister <a href="https://ministers.education.gov.au/clare/national-teacher-workforce-plan">Jason Clare</a> recognised this in teaching, saying “It’s also about respect. […] We need to stop bagging teachers and start giving them a wrap.” We need this <a href="https://patconaghan.com.au/local-mid-north-coast-gps-deserve-our-thanks-and-appreciation/">for GPs too</a>. </p>
<h2>5) Rural GPs are leaving</h2>
<p>It has always been challenging to attract GPs to country practice. Rural practice often involves a wider scope of practice, personal isolation and <a href="https://centralnews.com.au/2022/10/14/gps-bear-brunt-as-rural-australia-falls-behind-on-healthcare/">increased workloads</a> with less professional support. </p>
<p>Rural GPs often work long hours and have on call responsibilities. Jobs, schools and services for <a href="https://insightplus.mja.com.au/2017/44/families-come-first-for-gps-thinking-about-rural-practice/">GP families</a> can be difficult to access. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-burnt-out-health-workforce-impacts-patient-care-180021">A burnt-out health workforce impacts patient care</a>
</strong>
</em>
</p>
<hr>
<p>Despite a growing number of <a href="https://www.health.gov.au/our-work/national-rural-generalist-pathway">programs for educating and training rural doctors</a>, the uneven distribution of GPs may be <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">worsening</a>. </p>
<h2>6) Fewer overseas-trained doctors are arriving</h2>
<p>There is a <a href="https://apps.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/index.html">global shortage of all health-care workers</a>, which is expected to worsen. Supply of international medical graduates may drop as their options for work in other countries increases. Border closures during COVID have also reduced supply. </p>
<figure class="align-center ">
<img alt="Two young international medical graduates talk" src="https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is a global supply of doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paris-france-november-22-2022-doctor-2230732303">Shutterstock</a></span>
</figcaption>
</figure>
<p>International medical graduates make up more than <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">50% of the rural workforce</a>. However recent <a href="https://www.health.gov.au/topics/rural-health-workforce/classifications/dpa">changes</a> mean these doctors can now work in urban locations, rather than the more isolated practices in rural areas. This may worsen <a href="https://www.ausdoc.com.au/news/another-workforce-crisis-govts-img-rule-changes-slammed/">GP shortages in rural communities</a>.</p>
<p>International medical graduates have to <a href="https://www.acrrm.org.au/docs/default-source/all-files/43251-pathways-to-becoming-registered-brochure-f-web.pdf?sfvrsn=e6e69beb_4">fund their own training and assessment</a>. This starts with becoming <a href="https://www.amc.org.au/specialist/">registered as a doctor</a> in Australia and then involves <a href="https://www.racgp.org.au/education/imgs">training as a GP</a>. The training is <a href="https://medicalrepublic.com.au/red-tape-strangling-img-rural-supply/82701">long, arduous and expensive</a>, and doctors often need <a href="https://www.theguardian.com/australia-news/2022/jul/24/international-doctors-unable-to-work-in-australia-due-to-broken-system-experts-say">additional support</a>. There is also an ethical question of recruiting health-care workers from countries that <a href="https://www.smh.com.au/healthcare/the-global-race-to-lure-healthcare-workers-down-under-20220505-p5aiza.html">need their services more</a>. </p>
<p>While the Strengthening Medicare Taskforce supports GP care, it doesn’t identify the specific changes required to improve accessibility and affordability and requires significant structural change. </p>
<p>It will be months before the recommendations of the report can be translated into policy, and it may be years before radical changes can be implemented. Without addressing the GP shortage in the meantime, there may be a much smaller workforce to strengthen. </p>
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<strong>
Read more:
<a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">Emergency departments are clogged and patients are waiting for hours or giving up. What's going on?</a>
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<img src="https://counter.theconversation.com/content/199284/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone is a Fellow of the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine</span></em></p><p class="fine-print"><em><span>Jennifer May is a GP and Director of the University of Newcastle Dept of Rural Health which is in receipt of Commonwealth funding under the Rural Health Multidisciplinary Funding Training Programme.She is the co chair of the Medical Workforce Advisory Reform Committee
</span></em></p>More Australians are delaying care or going to emergency departments because they can’t see a GP. Here are six reasons why.Louise Stone, General practitioner; Associate Professor, ANU Medical School, Australian National UniversityJennifer May, Betty Fyffe Chair of Rural Health Director of University of Newcastle Dept of Rural Health, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1906662022-12-12T23:35:11Z2022-12-12T23:35:11ZWith so many GPs leaving the profession, how can I find a new one?<figure><img src="https://images.theconversation.com/files/499451/original/file-20221207-24-bxleyf.jpg?ixlib=rb-1.1.0&rect=46%2C18%2C6155%2C3484&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/african-male-pediatrician-hold-stethoscope-600w-1463202677.jpg">Shutterstock</a></span></figcaption></figure><p>Perhaps you have been happily attending the same GP for many years. They know your medical history better than anyone. Then all of a sudden they retire, or the practice closes, or it gets taken over by a bigger company and everything at the practice changes. Or maybe you’ve just had an unexpected visit to hospital and they ask who your GP is on discharge, then you realise you’re in need of one. </p>
<p>More than 80% of Australians <a href="https://pubmed.ncbi.nlm.nih.gov/29779298/">visit a GP</a> each year and those with chronic medical conditions will attend multiple times within the same period. It’s important to have a good GP who can coordinate your care. So how do you find a new one to develop a trusted relationship with? </p>
<p>As practising GPs ourselves, we are often asked: “Do you know a good GP?” This can be a somewhat difficult question to answer, as each person’s perception of “good” is highly subjective, dependent on many factors.</p>
<p>Studies of peoples’ preferences have varied results. One study found the <a href="https://pubmed.ncbi.nlm.nih.gov/21334160/">listening ability</a> of the GP to be important. Other studies found patients put more value in <a href="https://pubmed.ncbi.nlm.nih.gov/18332402/">clinical competency</a>, a <a href="https://bjgp.org/content/70/698/e676">trusting relationship or continuity of care</a>. </p>
<p>So a better question is: what GP will be a good fit for me?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gps-are-abandoning-bulk-billing-what-does-this-mean-for-affordable-family-medical-care-182666">GPs are abandoning bulk billing. What does this mean for affordable family medical care?</a>
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<h2>What factors are important to you? 6 aspects to consider</h2>
<p>Here are some tips to help speed up your search for your new GP. Remember though, it may take a few visits to develop a trusting relationship and know if the fit is right for you. </p>
<h2>1. Your health needs</h2>
<p>If you are young and healthy, a GP offering a convenient service and who is easy to book in quickly with may suffice. For those living with chronic complex conditions or disabilities who need to visit often, a consistent and thorough doctor is recommended. </p>
<h2>2. Cost</h2>
<p>Bulk-billing doctors are becoming rarer given the rising cost of services, salaries, equipment and utilities. To stay afloat, these doctors are having to see more patients in less time. </p>
<p>This could result in a poorer understanding of you as an individual and your health values and goals. Again, this might not be a problem for simple consults. But if you get a serious disease down the track, you might wish you’d had a regular GP all along, because they would know you and your history. </p>
<p>If you’re able to wear some extra cost but wondering how much to pay, consider the Australian Medical Association recommendation as your guide – a standard 15-minute <a href="https://www.ausdoc.com.au/news/rebate-gap-blows-out-47-standard-gp-consult/#:%7E:text=In%20its%20latest%20list%20of,currently%20sits%20at%20just%20%2439.10.">consult cost</a> is $86 with a $39 rebate from Medicare. </p>
<h2>3. Accessibility and practice size</h2>
<p>Consider the distance you need to travel and the opening hours you may need, including weekend availability. </p>
<p>Bigger practices are more likely to be able to get you in to see a doctor, if not your doctor, and often have longer opening hours. Having more than one preferred GP within the same practice can provide more flexibility and they will each be able to access your medical records and results. You may want to enquire also about disability access and telehealth options.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-businesses-are-offering-online-medical-certificates-and-telehealth-prescriptions-what-are-the-pros-and-cons-194154">More businesses are offering online medical certificates and telehealth prescriptions. What are the pros and cons?</a>
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<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="doctor's waiting room" src="https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499457/original/file-20221207-14-45b636.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You may be able to see a doctor more quickly at a larger practice.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-couple-face-masks-sitting-600w-1828070570.jpg">Shutterstock</a></span>
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<h2>4. Reviews</h2>
<p>Online recommendations can be tricky to interpret. Only <a href="https://www.center4research.org/believe-online-reviews-doctors/">6–8% of people</a> post online reviews for doctors. And there are plenty of people out there who have inappropriate requests or expectations of GPs, which may be their basis for a negative review. Also, someone who has been happily seeing their GP for decades is less likely to post a rating than a one-off visitor. </p>
<p>Be sure to consider what reasons were given for a negative review – was it because of actions taken, an attitude, or a personality clash? – and how those reasons align with your preferences. In saying that, community Facebook groups are often a hotspot for discussions about local GPs and recurrent positive recommendations can and should be held in higher regard. </p>
<h2>5. New doctors</h2>
<p>There are many young GPs starting off in the profession or new to the area. Many will be fantastically caring and competent. But these doctors are not going to come with recommendations yet. </p>
<p>These GPs often have plenty of appointment slots, and the most recent up-to-date training. Being an early adopter of their services could be to your benefit. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-you-fix-general-practice-more-gps-wont-be-enough-heres-what-to-do-195447">How do you fix general practice? More GPs won't be enough. Here's what to do</a>
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<h2>6. Sub-specialists</h2>
<p>Many GPs have special interests and advanced skills, such as skin cancer care, musculoskeletal medicine, women’s health or mental health. </p>
<p>They may have done postgraduate training, usually listed on the practice website along with their special interests. They are likely to have a shorter waiting time and lower costs than specialists – so consider these doctors if your needs match their expertise. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1541592411776090113"}"></div></p>
<h2>Other things to check</h2>
<p>About 80% of practices go through a <a href="https://www.semphn.org.au/general-practice-accreditation">practice accreditation process</a>, which proves attainment of standards set by the Royal Australian College of General Practitioners. Such practices will advertise this status on their website and at the entrance to the clinic.</p>
<p>You can also ask about a doctor’s qualifications and about the standard consultation length. This may range from 10 to 20 minutes. Don’t be afraid to ask these questions when calling a practice about your first visit.</p>
<p>The final and arguably most important test is how you connect when you meet them in person. Finding a GP can be like finding your favourite cardigan. You don’t know it’s your favourite until it has been worn in. </p>
<p>Similarly you don’t know that your GP is great until you’ve journeyed with them through some potentially challenging times of your life. We encourage you to use the above tips to find a suitable GP, then give them some time to get to know you and grow a therapeutic relationship. </p>
<p>With continuity of care, trust will grow, as will knowledge about you and your values. This will ultimately improve your overall health care experience. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
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<img src="https://counter.theconversation.com/content/190666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>‘See your GP’ is standard advice. But what if you don’t have one? Or yours is shutting up shop? Here’s how to find a new GP who suits you.David King, Senior Lecturer in General Practice, The University of QueenslandRhys Cameron, Senior lecturer, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1921632022-10-11T19:03:56Z2022-10-11T19:03:56ZSome GPs just keep their heads above water. Other doctors’ businesses are more profitable than law firms<figure><img src="https://images.theconversation.com/files/488898/original/file-20221010-57880-2zni7j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1920%2C1077&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/black-and-white-photo-of-window-with-message-9295975/">Sonny Sixteen/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Almost all GPs and most non-GP specialist doctors (such as cardiologists, gynaecologists and dermatologists) run private businesses to provide medical care in Australia. Business decisions can influence the costs of medical care, the care patients receive, and access to medical care in different geographic areas. </p>
<p>But until now, we’ve had no national data on the costs or profitability of running a private medical practice.</p>
<p>Our ANZ-Melbourne Institute Health Sector <a href="https://www.anz.com.au/content/dam/anzcomau/documents/pdf/ANZ-Melbourne-Institute-Health-Sector-Report.pdf?adobe_mc=MCMID%3D44747976514731566262638549714644871422%7CMCORGID%3D67A216D751E567B20A490D4C%2540AdobeOrg%7CTS%3D1665566472">Report</a>, out today, uses data from the Australian Bureau of Statistics on all medical businesses in Australia.</p>
<p>We examined trends in growth, costs and profitability, and how the financial health of doctors’ businesses has been affected during the COVID pandemic.</p>
<p>Among our findings, we show how medical businesses, in particular for non-GP specialists, remain very profitable compared to other businesses, including law, accountancy and finance.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a>
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<hr>
<h2>Why should we care about medical businesses?</h2>
<p>Many people seeking health care do not think about the costs involved, or the profitability of, running a private medical practice.</p>
<p>But the sudden <a href="https://www.abc.net.au/news/2022-08-11/tristar-medical-clinic-closures-to-leave-some-towns-without-a-gp/101322264">closure</a> of GP practices for financial reasons reduces access to health care for communities. For others, a focus on seeking profits means out-of-pocket costs can rise. </p>
<p>There are also more widespread <a href="https://www1.racgp.org.au/newsgp/professional/drop-in-national-bulk-billing-rate-signals-increas">reports</a> of reduced access to bulk billing (where there are no out-of-pocket costs).</p>
<p>So how doctors run their private businesses is very much in the public interest.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">Health worker burnout and 'compassion fatigue' put patients at risk. How can we help them help us?</a>
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</em>
</p>
<hr>
<h2>The growth of private practice</h2>
<p>It was not too long ago that GPs and non-GP specialists worked largely on their own. But the benefits of working with others has led to a growth in private group medical practice. </p>
<p>GPs were the first doctors to do this. Now almost 90% of GPs report working in a group practice. But other specialists are rapidly catching up, where almost 70% now work in a private group practice. </p>
<p>The total number of doctors in a solo private practice has fallen by 0.5% between 2013 and 2020, while the number in group private practices has increased by 28.9%.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Patient talking to doctor receptionist or health staff behind desk" src="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/488942/original/file-20221010-26-39u7f5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Groups practices can keep costs down by sharing the costs of premises, administration and support staff.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-receptionist-smiling-at-a-person-4269203/">Cedric Fauntleroy/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
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<p>Group practices can be good in keeping costs down by sharing the costs of premises, administration, nurses, and medical equipment. Working together can improve the quality of care and access to health care, as patients can easily see another GP in the practice if their preferred one is too busy. In a group practice, doctors can also more easily share knowledge. </p>
<p>But if businesses get too big, this could mean less choice for patients looking for a local doctor, and less competition. This could further increase out-of-pocket costs as there is less competitive pressure to keep fees low.</p>
<p>While more non-GP specialists are working in group private practice, they are also on average spending less time there. In 2020 they spent about three hours per week less in private practice compared to 2013.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/last-year-half-a-million-australians-couldnt-afford-to-fill-a-script-heres-how-to-rein-in-rising-health-costs-178301">Last year, half a million Australians couldn't afford to fill a script. Here's how to rein in rising health costs</a>
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<hr>
<h2>Rising profits and costs</h2>
<p>We show profits rose by an average of 2.4% a year for GP businesses and 5.3% a year for non-GP specialists businesses between 2005-6 and 2020-21. </p>
<p>Costs for GPs rose by an average 2.7% a year over the same time period. Turnover from total fees charged grew by 2.9%.</p>
<p>For non-GP specialists costs rose by an average 2% a year over the same time period, while turnover grew by 3.5%.</p>
<p>Overall the growth in costs for GP businesses was higher than for other specialists, and the growth in turnover was lower. This gap between costs and turnover has grown over time. </p>
<p>Non-GP specialists’ businesses made 50% more profit than GP businesses in 2020-21 ($216,468 and $144,485), compared to 14% more in 2005-6 ($120,452 and $105,924).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
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<hr>
<h2>Impact of COVID</h2>
<p>Medicare coverage of telehealth meant GPs avoided losing income from the fall in face-to-face visits because of COVID. So revenue from fees continued to increase, though at a lower rate than before 2020. </p>
<p>Medical practices could also claim JobKeeper payments to maintain employment of practice staff. This financial support meant the number of GP and non-GP specialist businesses winding up or going bust actually fell during 2019-20. In fact, the total number of medical businesses continued to grow throughout the pandemic. </p>
<p>Profits initially fell during COVID by 1.9% for GPs and by 4.5% for non-GP specialists between 2018-19 and 2019-20. </p>
<p>But profits bounced back the following year because of the pent-up demand during the pandemic. People who were avoiding health care because of COVID or who had their elective surgeries cancelled, came back and still needed care.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two surgeons operating" src="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/488943/original/file-20221010-11-5addt1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People who once had their elective surgeries cancelled can now go ahead.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/surgeons-performing-surgery-2324837/">Павел Сорокин/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>This was especially the case for non-GP specialists, where profits grew by 10.8% between 2019-20 and 2020-21 compared to 2.2% for GPs. </p>
<p>However, medical businesses, especially GPs, experienced sudden increases in costs as they adapted to COVID settings. For GP businesses, costs increased by over 8% during the pandemic (4.1% between 2018-19 and 2019-20, and by 4% between 2019-20 and 2020-21.</p>
<p>It is expected demand will remain high for private medical care provided by GPs and non-GP specialists as people who delayed care and treatment during the pandemic return to seek care. </p>
<p>In fact, medical businesses, especially non-GP specialists, remain very profitable compared to other businesses such as law, accountancy, finance, construction and agriculture. In 2021, the median gross profit per business (turnover minus costs before tax) was $216,468 for non-GP specialists, $120,452 for GPs, and $124,431 for legal businesses.</p>
<h2>Implications for patients</h2>
<p>Achieving good access to high-quality medical care requires medical businesses to be located in areas of need and where out-of-pocket costs are kept to a minimum for low-income populations.</p>
<p>The growth in private group medical practice can mean medical businesses are run more efficiently, with continuing cost pressures leading to the formation of larger medical groups, especially for non-GP specialists. </p>
<p>In most cases maintaining profitability of private medical businesses is necessary to ensure their survival and maintain access to medical care, as long as out-of-pocket costs don’t increase at the same time.</p><img src="https://counter.theconversation.com/content/192163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australia and New Zealand Banking Group for the annual report series 'ANZ-Melbourne Institute Health Sector Reports'. Professor Scott conducts the data analysis and writes the report. </span></em></p>The cost and profits involved in running a medical practice is everyone’s business. It can influence the type of health care you receive.Anthony Scott, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879842022-08-08T20:03:06Z2022-08-08T20:03:06ZWhy am I so tired and when is it time to see the doctor about it? A GP explains<figure><img src="https://images.theconversation.com/files/476813/original/file-20220801-24-vmtt8t.jpg?ixlib=rb-1.1.0&rect=0%2C141%2C7839%2C5741&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Everyone feels tired sometimes. But how do you know whether your tiredness is a problem worth seeing a doctor about? And with all the mental and emotional strain we have been under from the pandemic, isn’t it just normal to feel tired?</p>
<p>Tiredness is subjective; what’s normal for one person won’t be for the next. Many people see their GPs reporting tiredness (a recent study in Ireland found that it was <a href="https://www.researchgate.net/publication/11376157_Prevalence_of_fatigue_in_general_practice">present in 25% of patients</a>). </p>
<p>As a GP, my first question to someone who feels tired is: “how well can you function?”. </p>
<p>If tiredness is interfering with your everyday life and your ability to do what you like to do, it should be explored further.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman looks tired at work." src="https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476809/original/file-20220801-22375-w5zbiu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If your level of tiredness is outside the range of normal for you, chat to a GP about it.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fatigue-after-covid-is-way-more-than-just-feeling-tired-5-tips-on-what-to-do-about-it-179478">Fatigue after COVID is way more than just feeling tired. 5 tips on what to do about it</a>
</strong>
</em>
</p>
<hr>
<h2>Some common causes of persistent tiredness</h2>
<p>Poor sleep is an obvious and very common cause of tiredness. Often patients tell me “Oh, lack of sleep is not the cause, I sleep fine, possibly too much!” But on questioning they admit they don’t wake up feeling refreshed.</p>
<p>That’s a bit of a giveaway because it means their sleep quality is poor, even if the quantity seems enough. They could be suffering from sleep <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/sleep-apnoea">apnoea</a>, where breathing stops and starts while a person is asleep. Apnoea can lead to serious long-term health problems, so it’s worth investigating.</p>
<p>Alcohol can also wreak havoc on a person’s sleep quality and they wake feeling unrefreshed.</p>
<p>Another common cause of tiredness is depression – and don’t forget, someone can be depressed without feeling they have low mood. For example, they may feel <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression#symptoms-of-depression">irritable or frustrated, or struggle to concentrate</a>. This is concerning, because such patients may fly under the radar and not realise this is actually depression. Unexplained tiredness may be the predominant symptom of depression, with other symptoms only coming to light with careful questioning. </p>
<p>Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious long-term illness that, among other symptoms, causes people to feel extreme fatigue – well beyond the range of “normal” tiredness. It can begin with patients noticing a degree or type of tiredness different from their past experience, and can be difficult to diagnose in the early stages.</p>
<p>There are other potential causes of tiredness – problems such as low iron, thyroid disease, diabetes, kidney disease, heart disease and many more. Treatment for these can alleviate the tiredness too.</p>
<p>Tiredness also accompanies many illnesses, but should not persist after recovery.</p>
<p>The take-home message is this: if tiredness is interfering with your life, there are many possible causes and it’s worth speaking to a GP about it.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476810/original/file-20220801-67813-uha9wt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Poor sleep is a very common cause of tiredness.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What does ‘interfering with life’ actually look like?</h2>
<p>Screening tools for a concerning level of tiredness include the <a href="https://nasemso.org/wp-content/uploads/neuro-epworthsleepscale.pdf">Epworth Sleepiness Scale</a> and the <a href="https://www.mdcalc.com/calc/3992/stop-bang-score-obstructive-sleep-apnea">STOP-BANG</a> score. You can do both tests at home and take the results to your GP.</p>
<p>But even if you have normal scores, your tiredness is worth investigating if you:</p>
<ul>
<li><p>feel too tired to exercise (this can be a vicious cycle because regular exercise can actually give you more energy – however, it can be <a href="https://www.npr.org/sections/health-shots/2017/10/02/554369327/for-people-with-chronic-fatigue-syndrome-more-exercise-isnt-better">risky</a> for people with ME/CFS to exercise, so caution is required for these patients)</p></li>
<li><p>feel too tired to go out, see friends or do activities you once enjoyed</p></li>
<li><p>hit the alarm snooze button a lot because you don’t wake feeling refreshed</p></li>
<li><p>doze off in front of the TV regularly</p></li>
<li><p>spend the whole day wishing you could go back to bed.</p></li>
</ul>
<p>If, along with tiredness, you also have any of the following “red flags”, it is vital you see a GP sooner rather than later: unexplained weight loss, shortness of breath, recurrent fevers, bleeding from your bowels or gums, swollen and sore joints, or other new symptoms concerning you.</p>
<p>I sometimes get asked if wanting an afternoon nap is a red flag. That’s a tricky one; a late afternoon energy slump is pretty normal physiologically (we have whole cultures built around the idea of a siesta, and I often wish Australia was more open to the idea!).</p>
<p>And, of course, many of us lead busy lives and are subject to crushing expectations around work, study and parenting. Tiredness may not always be sign of a physical health problem, but rather that the balance between work and rest is not right.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476812/original/file-20220801-9120-s4sk8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Do you feel refreshed when you wake up?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>OK, I’m starting to realise my tiredness might be a problem. What now?</h2>
<p>Talk to your doctor. What happens next depends on the individual and unique factors at play. </p>
<p>Some people need investigating immediately if possible serious underlying causes are suspected.</p>
<p>However, there are often obvious ways to address lifestyle factors, and we’d start there. Is alcohol or caffeine interfering with your sleep? Do you have good <a href="https://www.cci.health.wa.gov.au/%7E/media/CCI/Mental-Health-Professionals/Sleep/Sleep---Information-Sheets/Sleep-Information-Sheet---04---Sleep-Hygiene.pdf">sleep hygiene habits</a>? Is your exercise level appropriate and your diet not <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071235/">too high in sugar</a>?</p>
<p>After we’ve tackled lifestyle factors, we can look at whether to investigate for health conditions that might be contributing to the tiredness. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476814/original/file-20220801-20-yzxuzi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Do you often fall asleep on the couch watching TV?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What about post-COVID fatigue?</h2>
<p>As I have <a href="https://theconversation.com/fatigue-after-covid-is-way-more-than-just-feeling-tired-5-tips-on-what-to-do-about-it-179478">written</a> before, fatigue is about more than feeling just tired:</p>
<blockquote>
<p>Tiredness can get better with enough rest, while fatigue persists even if someone is sleeping and resting more than ever.</p>
</blockquote>
<p>If you’re especially concerned about fatigue after recovering from COVID and are worried about long COVID, definitely talk to a doctor. </p>
<p>The factors at play are complex and unique to the individual, so a good doctor can help you work out when tiredness has crossed over into true fatigue.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/still-coughing-after-covid-heres-why-it-happens-and-what-to-do-about-it-179471">Still coughing after COVID? Here's why it happens and what to do about it</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/187984/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Yates is affiliated with the RACGP</span></em></p>A good doctor can help you work out when tiredness has crossed over into true fatigue.Natasha Yates, Assistant Professor, General Practice, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1840222022-05-31T14:03:35Z2022-05-31T14:03:35ZWeight loss advice from GPs really can help people slim down and stay that way – new research<figure><img src="https://images.theconversation.com/files/466302/original/file-20220531-22-fjzujg.jpg?ixlib=rb-1.1.0&rect=54%2C0%2C6082%2C4051&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People lost almost 4kg on average when working with a GP. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/attentive-middleaged-female-doctor-talk-senior-1639376224">fizkes/ Shutterstock</a></span></figcaption></figure><p>For people looking to lose weight, it can be hard to know where to start. Not only are there scores of commercial weight loss programmes to choose from, there’s also plenty of confusing and contradictory weight loss advice to be found online or in magazines. </p>
<p>But the best person to help you lose weight may actually be your family doctor, as our <a href="https://www.bmj.com/content/377/bmj-2021-069719.full?ijkey=FnARkmvxLOMFvlb&keytype=ref">recent review showed</a>. We found that weight loss programmes delivered by general practitioners (GPs) and their teams can help people lose weight and reduce their waist size. We also found that people were able to maintain their weight loss even after two years.</p>
<p>To conduct our review, we looked at 27 studies with data from 8,000 people. There was a lot of variation in the weight loss programmes offered by GPs. Some studies involved participants who only had one short advice session with a doctor, while others involved multiple visits with their GP. The length of the programmes also varied – from three months to three years. </p>
<p>Most sessions were conducted in person, while some were done over the phone or online. In some studies, nurses, dietitians and health coaches also gave weight loss advice to participants. </p>
<p>The advice GPs gave to participants usually included education about increasing physical activity and reducing calorie intake through self-monitoring. Sometimes weigh-ins and feedback was also included to motivate patients. Some studies also had GPs give patients specific diets or structured workout plans. </p>
<p>We found that, after a year, people who received help from their doctor lost an average of 3.7kg – 2.3kg more than people who did not receive help from their GP. While this difference in weight loss may seem small, even losing 2%-5% of body weight can have a range of health benefits, such as improved blood <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120182/">sugar levels</a>. We also showed that people who lost weight with help from their GP kept around 80% of it off when followed up two years later.</p>
<h2>Weight loss success</h2>
<p>Perhaps unsurprisingly, we found that the more contact a person had with their GP the better. Patients who saw their GP at least 12 times during the programme lost the greatest amount of weight. </p>
<p>We also found that the <a href="http://www.thelancet.com/retrieve/pii/S2213858720301170">two programmes</a> that had the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext">greatest weight loss</a> in a 12-month period were those that used a <a href="https://www.phc.ox.ac.uk/research/diet-plans">total diet replacement</a> plan. Total diet replacements involve replacing foods with a number of formula products such as shakes and provide between 800-1200 calories per day. These are mostly used in people with high sugar levels to try and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8234895/">reverse type 2 diabetes</a>. However anyone with obesity may use them to <a href="https://www.bmj.com/content/362/bmj.k3760">lose weight quickly</a>. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493523/">third best programme</a> involved weekly sessions for the first six months, followed by monthly sessions for 18 months thereafter. For the first month, participants were given prepackaged foods and meal replacement shakes. Replacement of foods may be <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12715">easier to stick to</a> at first as participants don’t need to decide what foods to make.</p>
<figure class="align-center ">
<img alt="a person steps onto a scale to weigh themselves." src="https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/466303/original/file-20220531-20-4xqgws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The right support can make it easier to lose weight – and keep it off.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unrecognizable-young-indian-woman-stepping-on-1988107514">Prostock-studio/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Our findings indicate that having the right kind of help and advice can make it easier for people to stick with a weight loss programme – and keep this weight off long term. We know from other research that having a weight loss plan can help people lose weight better than those who follow <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330835/">self-guided programmes</a>. </p>
<p>We know from other research that commercial weight loss programmes (such as Weight Watchers or Slimming World) can also help participants lose between <a href="https://www.bmj.com/content/343/bmj.d6500">0.8kg</a> and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30647-5/fulltext">2.7kg</a> on average in a year compared to those who didn’t attend such a programme. While these programmes may be moderately successful in helping people lose weight, the downside is that they’re often conducted in a group setting, may only be offered in more populated communities, and be costly, all of which could be off putting for some people.</p>
<p>But almost everyone has access to a GP, which may be another reason why weight loss advice given by them can be helpful for people looking to lose weight. Research also shows that having a <a href="https://pubmed.ncbi.nlm.nih.gov/24718585/">trusting relationship</a> with your GP may also make treatments – such as weight loss programmes – more successful.</p>
<p>In the future we are going to look at whether these programmes are effective for different ethnic groups, genders and people that live in deprivation. Many studies don’t report some of these <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880332/#:%7E:text=Most%20of%20the%2094%20studies,and%201.0%25%20were%20Native%20Americans.">characteristics</a> so we must make sure we are reducing inequalities by offering these programmes. </p>
<p>An important consideration in all of this is that doctors are already overworked – and often <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis">don’t have the time</a> to deliver weight loss programmes. But our study also showed that advice given by a member of the GP team – such as a nurse or health coach – worked just as well. </p>
<p>If you’re someone looking to lose weight, the best <a href="https://www.nhs.uk/better-health/lose-weight/additional-weight-loss-support/">weight loss programme</a> is the one you’re likely to stick with. But speaking with your GP may helpful, especially if you don’t know where to get started.</p><img src="https://counter.theconversation.com/content/184022/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Liz Sturgiss receives funding from the National Health and Medical Research Council for an Investigator Grant to support her salary. </span></em></p><p class="fine-print"><em><span>Claire Madigan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our study showed that people who followed advice from their GP kept almost all of the weight they lost off two years later.Claire Madigan, Senior Research Associate, Centre for Lifestyle Medicine and Behaviour, Loughborough UniversityLiz Sturgiss, Senior Research Fellow, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1744582022-01-07T04:48:20Z2022-01-07T04:48:20ZI’ve tested positive to COVID. What should I do now?<figure><img src="https://images.theconversation.com/files/439762/original/file-20220106-25-wsffne.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5815%2C3873&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>For two years, COVID has dominated our world. In Australia, we’ve tested every sniffle, undergone extensive lockdowns, and double-vaccinated <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/numbers-statistics">more than 90%</a> of adults to combat this lethal virus.</p>
<p>So, it’s understandable our first reaction when we test positive to COVID ourselves is to panic.</p>
<p>However, a positive test doesn’t mean you will necessarily end up in hospital.</p>
<p>As a GP, here’s my advice on what you should do.</p>
<h2>When you test positive</h2>
<p>If you test positive on a rapid antigen test at home, you’re <a href="https://www.abc.net.au/news/2022-01-05/scott-morrison-rat-tests-national-cabinet/100739940">no longer required to get a PCR test</a>.</p>
<p>If you have symptoms and cannot get either a PCR or a rapid antigen test, you should assume you have COVID and self-isolate until you can get tested.</p>
<h2>Who should you tell?</h2>
<p>Tell a support person – someone who will be able to check on you every day, either in person (taking appropriate precautions) or by phone.</p>
<p>Also notify your work and cancel any other commitments you have coming up for the following week.</p>
<p>Contact tracing is completely overwhelmed in most states and territories, so make sure to notify your <a href="https://www.coronavirus.tas.gov.au/keeping-yourself-safe/contact-tracing/types-of-contacts">close contacts</a> yourself.</p>
<p>Currently, this is <a href="https://www1.racgp.org.au/newsgp/clinical/new-national-definition-of-covid-close-contact">defined as</a> a person who has spent four hours or more with you in a household or “household-like” setting while you’re infectious, which includes the two days before you got symptoms. Realistically, someone can catch it from you in much less than four hours, so notifying anyone you spent time with (even if less than four hours), would make medical sense.</p>
<p>In <a href="https://www.abc.net.au/news/2022-01-06/changes-to-victoria-covid-testing-rules-rat-pcr/100741694">some states</a> you are asked to notify the public health unit that you’ve tested positive. But at the time of writing there’s no national approach to self-reporting.</p>
<h2>Only inform your doctor if you have certain conditions</h2>
<p>Don’t automatically notify your GP. In many cases, if you’re young, fit and healthy there’s no benefit to you.</p>
<p>The current <a href="https://covid19evidence.net.au/wp-content/uploads/FLOWCHART-1-PATHWAYS-TO-CARE-V1.1.pdf">national recommendations</a> for treating COVID suggest adults with mild illness and no other risk factors may manage their symptoms at home.</p>
<p>With tens of thousands of people being diagnosed daily – and GPs rolling out booster vaccines, vaccines for children, and continuing our usual work – we don’t have capacity to review every person in Australia who’s a positive test each day. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1478990040629841921"}"></div></p>
<p>However, certain people testing positive should arrange a telehealth consultation with a GP regardless of how well they feel on receiving the news.</p>
<p>This includes people who are over 65, pregnant, immunocompromised, or are both unvaccinated/partially vaccinated and have certain diseases like diabetes, obesity, kidney, heart, liver or lung disease.</p>
<p>As people in this group are at higher risk of deteriorating, they may be able to <a href="https://monashhealth.org/patients-visitors/coronavirus/satellite-clinic/?fbclid=IwAR3PQEDv5yKhVvgVHrtfMLgUEerQSEZ9Nq1yMifJiB6cWt1F_Xv7kCg8edA">access medications</a> such as antiviral therapy to reduce that risk. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-still-not-too-late-to-fix-the-rapid-antigen-testing-debacle-why-the-national-cabinet-decision-is-wrong-and-must-be-reversed-174391">It's still not too late to fix the rapid antigen testing debacle. Why the national cabinet decision is wrong and must be reversed</a>
</strong>
</em>
</p>
<hr>
<h2>Treating ourselves at home</h2>
<p>Most of us will be treating ourselves at home.</p>
<p>This will <a href="https://www.health.nsw.gov.au/Infectious/factsheets/Pages/managing-covid-at-home.aspx">usually apply to people</a> who are under 65, aren’t pregnant, have had at least two doses of a COVID vaccine, and don’t suffer from any chronic conditions.</p>
<p>Here are some things to consider:</p>
<ul>
<li><p>make sure your home is as safe as possible for others who live there. It’s <a href="https://www.smh.com.au/national/how-we-lived-with-a-covid-positive-person-and-avoided-infection-20211226-p59k8v.html">not inevitable</a> everyone at home will catch it from you, especially if you keep it <a href="https://ozsage.org/media_releases/10-steps-to-reduce-sars-cov-2-transmission-risk-at-home/">well ventilated</a></p></li>
<li><p>as you’re not allowed to leave the house at all (except for <a href="https://www.healthdirect.gov.au/coronavirus-covid-19-self-isolation-faqs">urgent medical care</a>), ensure you have ways of getting food and medication, such as via home delivery services</p></li>
<li><p>rest, keep up your fluids, and treat pain and fever symptoms with over-the-counter medications if needed, like paracetamol and ibuprofen </p></li>
<li><p>nausea, vomiting and diarrhoea aren’t uncommon. If you experience any of these, eat small meals more often, stick to “white coloured” foods (pasta, rice, potato, white bread), and drink enough for your urine to look pale</p></li>
<li><p>continue your usual medications. It’s very important you don’t stop taking these, unless your GP specifically advises otherwise </p></li>
<li><p>if you have access to an oxygen monitor, use it <a href="https://reliefweb.int/sites/reliefweb.int/files/resources/oximeter-poster_rev3.pdf">three times a day</a> or if you feel your breathlessness is worsening. If your levels are 92% or lower, you need urgent review. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7055753/">Don’t rely</a> on a smart watch for oxygen monitoring.</p></li>
</ul>
<p>Here are some further helpful guides to <a href="https://www.racgp.org.au/clinical-resources/covid-19-resources/patient-resources/managing-mild-covid-19-at-home">managing COVID</a> <a href="https://www.gps-can.com.au/covid19-blog/a-guide-self-isolation">at home</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-tips-for-ventilation-to-reduce-covid-risk-at-home-and-work-151758">5 tips for ventilation to reduce COVID risk at home and work</a>
</strong>
</em>
</p>
<hr>
<h2>When to get medical help</h2>
<p>The national Healthdirect website <a href="https://www.healthdirect.gov.au/managing-covid-19/monitoring-covid-19-symptoms#contact-gp">suggests</a> asking yourself these questions morning, afternoon and night:</p>
<ul>
<li><p>can I get my own food? </p></li>
<li><p>can I drink? </p></li>
<li><p>can I go to the toilet normally?</p></li>
<li><p>can I take my regular medication? </p></li>
</ul>
<p>If you answer “no” to any of these questions, call your GP for a telehealth assessment.</p>
<figure class="align-center ">
<img alt="Person sick at home holding chest" src="https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439767/original/file-20220107-25-40vv6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s important to speak to your GP if your condition deteriorates.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Some parts of Australia have systems where <a href="https://www.healthdirect.gov.au/managing-covid-19/monitoring-covid-19-symptoms#monitored">home monitoring</a> takes place under a management plan devised by a health-care provider. Your GP will help you access this if appropriate. </p>
<p>You may also like to complete a <a href="https://www.gps-can.com.au/covid19-blog/i-have-covid-the-infection-now-what?fbclid=IwAR0wt05dZlV1AGHlY5dGEcf4dp_nDYqQA-IVEkwzKyGqJurT9dtzqTBgmD0">daily symptom checklist</a>.</p>
<h2>When to go to hospital</h2>
<p>Bypass your GP, go to straight to hospital, or call 000 if you develop any of the following:</p>
<ul>
<li><p>breathlessness, so you’re unable to speak in sentences, for example you <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527530/">cannot count to 20 in a single breath</a></p></li>
<li><p>fainting, unusually sleepy (difficult to rouse) or lethargic, or become unconscious at any point</p></li>
<li><p>skin turning blue or pale, or becoming clammy and cold</p></li>
<li><p>pain or pressure in the chest</p></li>
<li><p>confusion</p></li>
<li><p>passing no urine or a lot less urine than usual</p></li>
<li><p>coughing up blood.</p></li>
</ul>
<h2>When will you be safe to stop isolation?</h2>
<p>Current guidelines on this are complicated, vary from state to state, and change frequently.</p>
<p>For starters however, you can expect at least seven days of isolation.</p>
<p>Rules around safely stopping isolation centre on protecting both yourself and others. Therefore, as a general rule, you may stop isolating once you’re no longer infectious (evidenced by a negative PCR or rapid antigen test), your symptoms have passed (mild/occasional coughing is OK as this can last weeks) and you feel well enough to return to your normal life. </p>
<p>It’s best to check local requirements before stopping your isolation.</p>
<p>Finally, if you’re reading this before having tested positive, now is a great time to <a href="https://www.qld.gov.au/__data/assets/pdf_file/0016/230605/covid-ready-kit.pdf">do some planning and put preparations in place</a>, just in case you do.</p><img src="https://counter.theconversation.com/content/174458/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Yates is affiliated with the RACGP </span></em></p>Whether you’ve tested positive on a PCR or a rapid antigen test, here are a GP’s tips of how to manage your condition.Natasha Yates, Assistant Professor, General Practice, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1661352021-08-20T10:13:42Z2021-08-20T10:13:42ZWhy remote consultation with a doctor is difficult – and how it can be improved<p>Before the pandemic, billboards in London, England, advertised a <a href="https://www.standard.co.uk/escapist/health/how-doctors-are-turning-smartphones-into-surgeries-with-video-appointments-and-assessment-via-text-a3188806.html">doctor-in-your-pocket</a> service. Targeted at busy commuters, it consisted of a smartphone app and a promise of a video link-up to a real doctor within 45 minutes. What’s not to like?</p>
<p>Plenty. The pop-up video doc may be fine, on this occasion, for busy accountant Adesh Patel, who wants an antibiotic in the post for his septic finger. Indeed, patients like him may not even need a video call, they can explain their symptoms to a doctor by phone. The video link was, arguably, a commercial gimmick to lure the <a href="https://theconversation.com/online-gp-consultations-threaten-to-create-a-two-tier-healthcare-system-100121">worried well</a>. </p>
<p>But what about Adesh’s 79-year-old grandmother, Adiya Patel? She had a hip replacement five years ago and is getting similar pains in the other hip. If you didn’t know her well, you’d think she needed another operation, but her longstanding GP, Dr Choudhury, knows that she wants to avoid surgery after a reaction to an anaesthetic last time. </p>
<p>He’s been helping her lose weight so that the operation won’t be needed. Adiya is miserable after her husband died last year and has a touch of heart failure, which sometimes makes her breathless. All this is controlled by regular chats and various tablets that Dr Choudhury (who speaks her native language) has tweaked over the years. She’s very fond of him. </p>
<p>In his face-to-face surgery today, Dr Choudhury will see: Lydia Poliakov, a 53-year-old shop assistant who has found a lump on her breast; six-month-old Archie Merton who’s got a high fever and is not eating; and Jim Brown, an unemployed man who has no family, no home, no mobile phone and no money. Jim needs regular foot and eye checks for his diabetes and a weekly prescription for methadone since he came off heroin. </p>
<p>These fictitious cases illustrate the findings of a <a href="https://www.frontiersin.org/articles/10.3389/fdgth.2021.726095/full">recent study</a> my team did into why some remote consultations by video are efficient, effective and well-received but others are logistically cumbersome, technically inadequate and associated with deficiencies in care, such as missed diagnoses or a poor patient experience. </p>
<p>While it’s impossible to generalise, remote consultations seem to be less suitable for people who</p>
<ul>
<li>are very young or very old</li>
<li>are very unwell with a high-risk condition, such as pneumonia</li>
<li>have complex health or wider needs</li>
<li>want or need a physical examination</li>
<li>have difficulty communicating (though the hard-of-hearing may prefer a video link where neither party wears a mask)</li>
<li>need supervised check-ups, for example, for controlled drugs</li>
<li>do not own, or wish to use, technologies like smartphones </li>
<li>lack privacy at home.</li>
</ul>
<h2>‘Remote by default’</h2>
<p>When former health minister Matt Hancock <a href="https://www.gov.uk/government/speeches/the-future-of-healthcare">announced a year ago</a> that all medical consultations would henceforth be “remote by default”, he had in mind patients like young Mr Patel with one-off, easily sorted problems. Setting up remote services to meet that kind of need is almost as easy as putting up a lemonade stall. </p>
<p>Providing remote services for a wider range of patients with more complex needs (physical, mental and social) is vastly more challenging. But that doesn’t mean it’s impossible. Healthcare providers need to invest in the right equipment, streamline access (for example, by allowing receptionists to channel each web request to the most appropriate doctor), train staff and patients in how to get the most out of a remote consultation (whether telephone, video or web-consult), and provide information on what is and isn’t suitable for each consultation type. With this kind of groundwork, some complex consultations can be undertaken safely remotely. </p>
<p>It turns out that old Mrs Patel, who was finding the walk to the surgery increasingly difficult on her painful hip, finds remote consultations with Dr Choudhury quite acceptable as long as one of her relatives is available to help her connect to the iPad, she can be sure to get her own GP, and everyone keeps out of the living room while she’s talking to the doctor. </p>
<p>Ms Poliakov, too, is a candidate for a remote consultation. She knows she has a breast lump, and at her age, there’s no doubt it needs to be seen urgently. A telephone or e-consultation with her GP will get her a prompt referral to the breast clinic. What Mrs Poliakov needs is accurate information when she searches her symptom, encouragement not to ignore that lump, and a fast-track for her request for a call-back. </p>
<p>But a face-to-face service will always be needed for patients like the unwell baby with a high fever and the homeless person with multiple care needs and no technology. </p>
<p>Our research has shown that GP consultations should not be remote by default, but that with attention to infrastructure, training and planning, remote consultations could become a realistic option for a much wider range of people than the healthy young professionals towards whom they were originally targeted.</p><img src="https://counter.theconversation.com/content/166135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trish Greenhalgh’s research is funded from the following sources: National Institute for Health Research (BRC-1215-20008), ESRC (ES/V010069/1), Wellcome Trust (WT104830MA) and Health Data Research UK (HDRUK2020.139).</span></em></p>Remote consultations with the GP are no longer just for busy young professionalsTrish Greenhalgh, Professor of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1605322021-07-02T03:09:51Z2021-07-02T03:09:51ZBe kind: GP receptionists are taking the heat with every policy update during COVID, vaccines included<figure><img src="https://images.theconversation.com/files/400672/original/file-20210514-13-15pp9gi.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C997%2C529&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/receptionist-woman-office-reception-wearing-face-1726918939">from www.shutterstock.com</a></span></figcaption></figure><p>Phones are ringing off the hook at <a href="https://www.ausdoc.com.au/news/chaos-reigns-gps-swamped-demand-astrazeneca-vax-under40s">GP clinics</a> <a href="https://www.annfammed.org/content/covid-19-collection-global-primary-care-during-covid-19">with people</a> desperate to know when and how they can be vaccinated against COVID-19. </p>
<p>Every time there is a change in recommendations or advice, medical receptions field calls from concerned people trying to book in to talk to a GP or to cancel bookings. This is on top of supporting patients and juggling the extra workload required to perform COVID-19 triage, screening and telehealth.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1409459128603275264"}"></div></p>
<p>GPs and practice nurses are considered <a href="https://www1.racgp.org.au/ajgp/coronavirus/australias-primary-care-covid19-response">central and front line</a> in Australia’s primary care COVID-19 response. However, GP receptionists are one step in front. </p>
<p>Their role has changed considerably during the pandemic, taking on functions and learning new skills no-one planned for. We must not forget them and the stressful work they do.</p>
<h2>All in a day’s work</h2>
<p>Medical receptionists are an integral part of <a href="https://www.racgp.org.au/download/Documents/Standards/RACGP-Standards-for-general-practices-5th-edition.pdf">general practice teams</a> and GP clinics would be challenged to exist without them. Doctors, nurses and other staff rely on medical receptionists to create a friendly, welcoming and well-organised front-of-clinic for patients. </p>
<p>Some people assume medical receptionists “just” answer phone calls, notify doctors when patients have arrived and make follow-up appointments. But this not only understates their true impact and influence on our health system, it does not acknowledge the challenges and pressures of their work.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-younger-australians-decide-about-the-astrazeneca-vaccine-a-gp-explains-163733">How can younger Australians decide about the AstraZeneca vaccine? A GP explains</a>
</strong>
</em>
</p>
<hr>
<p>Long before the pandemic, medical receptionists were <a href="https://www.semanticscholar.org/paper/Medical-receptionists-in-general-practice%3A-Who-a-Patterson-Mar/4b51152b3a994796f1c9dd8ceaa772e254ef5e6c">increasingly undertaking clinical duties</a>, performing tasks involving direct patient assessment, monitoring and therapy. </p>
<p>Medical receptionists were typically in this situation because of a lack of <a href="https://www.uow.edu.au/media/2020/research-finds-primary-health-care-nurses-losing-work-during-pandemic.php">financial support for practice nurses</a>. But, given receptionists are not trained health professionals and are continuously handling confidential information about patients, there’s the risk they may be held <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjFmb62ocPxAhXESH0KHWKvDyMQFjAKegQIGRAD&url=https%3A%2F%2Fespace.library.uq.edu.au%2Fview%2FUQ%3A8923%2FRisk1.pdf&usg=AOvVaw07fkvpK9ipdDfyH6ig8Wve">legally liable</a> for making a mistake. </p>
<h2>Then came the pandemic</h2>
<p>The role of medical receptionists has profoundly changed due to the pandemic, though they have not being included in pandemic planning. </p>
<p>The Royal Australian College of General Practitioners has said <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">many receptionists</a> have been providing health and safety advice to patients and the wider community.</p>
<p>They are routinely asking patients questions about their travel history and symptoms, and monitoring body temperature to assess the risk of a patient being infected with COVID-19, despite not being trained to make clinical decisions.</p>
<p>They are increasingly performing <a href="https://www1.racgp.org.au/newsgp/clinical/should-suspected-coronavirus-patients-present-to-g">basic triage</a> over the phone and at the front desk, essentially assessing “how sick” a patient is and how timely their care needs to be.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1377021338011901955"}"></div></p>
<p>Particularly during the pandemic, it is usually their decision whether a patient is granted a face-to-face appointment, seen in their car, placed in an isolation room for their consultation, or asked to go to the hospital instead. </p>
<p>Medical receptionists are also relied on for <a href="https://www1.racgp.org.au/newsgp/racgp/racgp-recognises-the-unheralded-heroes-of-covid-19">technical support</a> for telehealth and to train clinicians and patients to use it. </p>
<p>Deciding if a patient is suitable for telehealth alone requires a basic understanding of what the doctor might need. We wouldn’t expect any medically untrained person to make these decisions, yet we expect our receptionists to.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/view-from-the-hill-scott-morrisons-astrazeneca-hand-grenade-turns-into-cluster-bomb-163680">View from The Hill: Scott Morrison's AstraZeneca 'hand grenade' turns into cluster bomb</a>
</strong>
</em>
</p>
<hr>
<h2>No wonder it’s stressful</h2>
<p>Medical receptionists are rightly concerned about <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">contracting COVID-19</a> as they are so close to unwell patients in the waiting room.</p>
<p>Threats of violence from frightened patients are also <a href="https://www1.racgp.org.au/newsgp/professional/violence-towards-gps-and-staff-a-growing-problem-n">now a reality</a>. And when a patient has not been booked in correctly, or worse, when a patient enters a consultation room showing COVID-19 symptoms, they cop dissatisfaction from clinicians and patients alike.</p>
<figure class="align-center ">
<img alt="Woman looking stressed or scared wearing a mask" src="https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Working as a medical receptionist in a pandemic can take its toll.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/receptionist-woman-wearing-covid-ffp2-face-1925465327">from www.shutterstock.com</a></span>
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</figure>
<p>The <a href="https://medicalrepublic.com.au/emotional-rescue-patients/7049">emotional demand</a> on medical receptionists is also very high. Supporting clinical teams and their personal feelings and expressions is now part of the job, as well as advocating for, and empathising with patients.</p>
<p>They do all this for an average <a href="https://www.payscale.com/research/AU/Job=Medical_Receptionist/Hourly_Rate">A$23.96 an hour</a>, much less than administrative or secretary work outside the health-care sector. </p>
<h2>Training and support are critical</h2>
<p>There is no required qualification to become a medical receptionist. However, courses such as a Certificate III in Business Administration or Certificate IV in Health Administration are <a href="https://www.seek.com.au/career-advice/role/medical-receptionist">recommended</a>. Truthfully, no training exists to equip medical receptionists for the additional pressures of the coronavirus pandemic. </p>
<p>Informal tips are circulating about how practice owners can <a href="https://www.wolterskluwer.com/en/expert-insights/9-ways-to-fight-burnout-in-overworked-medical-staff">support staff to avoid burnout</a>, and also how medical receptionists can <a href="https://www.avant.org.au/news/the-subtle-art-of-good-triage-for-medical-receptionists/">enhance their clinical and triage work</a>. </p>
<p>Unfortunately, current tips and training do not address the fundamental problem of medical receptionists not being recognised, trained or paid accordingly for their growing clinical, management and administrative work. </p>
<h2>Get vaccinated, be kind</h2>
<p>GP clinics still play a vital role in getting Australians vaccinated and helping us emerge from the pandemic. That’s on top of their existing role.</p>
<p>Receptionists are at the front line of this pandemic, changing what they do at a moment’s notice to keep the rest of their teams and community safe. Their many hardships are well overdue for our respect and recognition.</p>
<hr>
<p><em>Tracey Johnson, CEO of Inala Primary Care, a large GP clinic and charity in Queensland, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/160532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Ball receives funding from the National Health and Medical Research Council, RACGP Foundation, VicHealth and Queensland Health. Lauren is an Executive Committee member of the Australasian Association of Academic Primary Care and on the Editorial Advisory Committee of the Australian Journal of General Practice. </span></em></p><p class="fine-print"><em><span>David is an Executive Committee member of the Australasian Association of Academic Primary Care.</span></em></p><p class="fine-print"><em><span>Katelyn Barnes is an Executive Committee member of the Australasian Association of Academic Primary Care.</span></em></p>Medical receptionists have taken on new roles during the pandemic, which no-one planned for. We must not forget them and the stressful work they do.Lauren Ball, Associate Professor/ Principal Research Fellow, Griffith UniversityDavid Chua, Primary heath care research fellow, Griffith UniversityKatelyn Barnes, Postdoctoral Research Fellow, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1603572021-05-16T19:55:36Z2021-05-16T19:55:36ZI’m over 50 and can now get my COVID vaccine. Can I talk to the GP first? Do I need a painkiller? What else do I need to know?<figure><img src="https://images.theconversation.com/files/400439/original/file-20210513-15-1d1vv8f.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-smiling-young-caucasian-woman-nurse-1769848013">from www.shutterstock.com</a></span></figcaption></figure><p>People aged 50 and over <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/getting-vaccinated-for-covid-19/when-will-i-get-a-covid-19-vaccine">are now officially eligible</a> to receive the AstraZeneca COVID-19 vaccine from selected GPs. </p>
<p>Although some practices have had permission to <a href="https://www1.racgp.org.au/newsgp/clinical/gps-with-astrazeneca-stockpile-turn-attention-to-v">provide the vaccine early</a> if they had excess stock, this marks a major step forward in Australia’s vaccination program.</p>
<p>People over 50 now have a choice of where to get vaccinated: their own GP (if taking part in the vaccination rollout), another GP practice (if their own GP is not), or respiratory clinics and mass vaccination hubs in some states.</p>
<p>Here are some practical things to think about when booking an appointment.</p>
<h2>Can I speak to the GP first?</h2>
<p>As a GP, I have been recommending patients access a vaccine from wherever is the most convenient for them. This may be from a mass vaccination hub or respiratory clinic, and not actually from a GP. However, some patients are hesitant and/or still have questions. If so, they do need to speak to a GP before they book for a vaccine. </p>
<p>The time to raise questions is not when you have turned up for your injection; most facilities allocate around 3-5 minutes for the doctor or nurse to spend with each patient. This does not allow time for prolonged discussion. </p>
<p>Instead, in the days before your vaccine, discuss concerns with your regular GP (if you have one). They know you and your medical history so are better placed to tailor advice to your individual situation. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/im-over-50-and-can-now-get-my-covid-vaccine-is-the-astrazeneca-vaccine-safe-does-it-work-what-else-do-i-need-to-know-159814">I'm over 50 and can now get my COVID vaccine. Is the AstraZeneca vaccine safe? Does it work? What else do I need to know?</a>
</strong>
</em>
</p>
<hr>
<p>If your GP is not one of the practices administering the vaccine, or if you don’t have a regular GP, you may want to book an appointment with a GP at the practice where you plan to get it, with the sole purpose of discussing your concerns.</p>
<p>Even if you book your vaccine through a GP clinic, it may not be a GP administering the vaccine. It may be a practice nurse, who is experienced at giving a range of vaccines and will have taken <a href="https://www.health.gov.au/covid-19-vaccination-training-program">the same mandatory training</a> as a GP in administering COVID-19 vaccines.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-asthma-diabetes-or-another-illness-can-i-get-my-covid-vaccine-yet-160602">I have asthma, diabetes or another illness — can I get my COVID vaccine yet?</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1235&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1235&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1235&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Department of Health/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>What’s the best time to have my vaccine?</h2>
<p>The best time to get vaccinated against COVID-19 is as soon as possible, once you have had all your questions answered. However, there are a few things you may need to consider.</p>
<p><strong>If you feel unwell</strong></p>
<p>If you feel very unwell on the day, especially if you have a high fever (over 38°C), you need to postpone your vaccine. This is partly because your immune system may not respond optimally to the vaccine, and partly so symptoms after the vaccine <a href="https://www.immunize.org/askexperts/contraindications-precautions.asp">aren’t confused with symptoms</a> from an underlying illness.</p>
<p><strong>If you want the flu vaccine too</strong></p>
<p>It’s best to leave <a href="https://www.health.gov.au/resources/publications/covid-19-vaccination-atagi-advice-on-influenza-and-covid-19-vaccines">at least 14 days</a> between your influenza and COVID-19 vaccines. It’s likely safe to have them both together, however this is <a href="https://www.uhbw.nhs.uk/assets/1/comflucov_faqs.pdf">still being tested</a>. Also, if you happen to get a reaction to one of them, you will know which one you have reacted to.</p>
<p><strong>If it’s time for your mammogram</strong></p>
<p>As the vaccine can cause a temporary swelling of the lymph nodes in the armpit, women are <a href="https://theconversation.com/covid-vaccine-may-lead-to-a-harmless-lump-in-your-armpit-so-women-advised-to-delay-mammograms-for-6-weeks-159529">advised</a> to either have a mammogram first, or delay it until six weeks after vaccination. This advice is particularly relevant as we start to vaccinate women 50 and over, the key target group for Australia’s <a href="https://www.health.gov.au/initiatives-and-programs/breastscreen-australia-program">breast cancer screening</a> program.</p>
<p><strong>If you can, book before a scheduled day off</strong></p>
<p>About <a href="https://www.ausvaxsafety.org.au/safety-data/covid-19-vaccines">20% of people report missing work</a>, study or routine duties for a short period after their first AstraZeneca vaccine. So have your vaccine the day before a scheduled day off work if possible.</p>
<h2>Should I take a painkiller directly before or after my vaccine?</h2>
<p>Unless you take common painkillers such as paracetamol, ibuprofen or aspirin to regularly to treat an underlying illness, do not take medications that control pain and/or fevers before your vaccine. </p>
<p>You may use them after the shot but only if you need to treat symptoms that are worrying you. Overall it is best to avoid taking them at all as they may curb your immune response.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person taking painkillers with glass of water" src="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Taking common over-the-counter painkillers can curb your immune response.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-girl-holding-pill-glass-water-718784776">from www.shutterstock.com</a></span>
</figcaption>
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<p>Both paracetamol and ibuprofen can <a href="https://journals.lww.com/ebp/Citation/2021/03000/Does_premedication_with_ibuprofen_affect_the.19.aspx">reduce the immune response to other vaccines</a>, particularly in children, although we’re not certain how much this affects their overall immunity to that disease.</p>
<p>One <a href="http://s0.uploads.ru/IHedb.pdf">study</a> showed taking aspirin, paracetamol or ibuprofen resulted in suppression of part of our immune response to viruses. And another study, this time in <a href="https://jvi.asm.org/content/95/7/e00014-21">mice</a>, revealed anti-inflammatory medications can impair production of some immune molecules after COVID-19 infection. </p>
<p>While none of this is strong evidence against taking these medications around a COVID-19 vaccine, the take-home message is not to take them if you don’t need to.</p>
<h2>What about exercise before and after the vaccine?</h2>
<p>Being physically fit can help you <a href="https://bjsm.bmj.com/content/45/12/987">fight off upper respiratory tract infections</a>. However does that translate to exercise also helping your immune response to vaccines? In other words, if you exercise before or after a vaccination will it work better? </p>
<p>There is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159113005023?via%3Dihub">evidence</a> exercise can help improve the response to some vaccines, particularly the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159119306518">influenza</a> ones, but this does <a href="https://cmr.asm.org/content/32/2/e00084-18">not apply to all vaccines</a>. </p>
<p>While the jury is still out on whether your COVID-19 vaccine will work better if you exercise around the time of having it, here is my suggestion: don’t exercise more than you usually do in the days before or after your shot. </p>
<p>Muscle pain and fatigue are two of the commonest side-effects from the COVID-19 vaccine, and are also normal responses to increasing your exercise. Avoid complicating the picture by maintaining your usual fitness regimen, and give yourself some leeway in the days after the vaccination where you may be feeling the side-effects from it.</p>
<p>The US Centers for Disease Control <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html">recommends</a> using or exercising your arm after the shot to help reduce pain and discomfort (although not to help the vaccine work better).</p>
<hr>
<p><em>Use the government’s <a href="https://www.health.gov.au/resources/apps-and-tools/covid-19-vaccine-eligibility-checker">vaccine eligibility checker</a> to see if you’re next in line for the COVID-19 vaccine, and where you can get vaccinated.</em></p><img src="https://counter.theconversation.com/content/160357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Yates is affiliated with RACGP. </span></em></p>Australians over 50 can get their AstraZeneca vaccine from a GP clinic from today. Here’s what you need to know when you book yourself in.Natasha Yates, Assistant Professor, General Practice, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1585192021-04-09T05:06:55Z2021-04-09T05:06:55ZAustralian vaccine rollout needs all hands on deck after the latest AstraZeneca news, mass vaccination hubs included<figure><img src="https://images.theconversation.com/files/394155/original/file-20210409-21-sz4t6e.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C998%2C616&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vax-day-immunization-campaign-mass-vaccination-1882915933">from www.shutterstock.com</a></span></figcaption></figure><p>Australia’s vaccine rollout is <a href="https://www.abc.net.au/news/2021-04-08/australia-new-coronavirus-vaccine-rollout-plan-what-we-know/100057354">due to be reset</a> after the news <a href="https://www.health.gov.au/news/atagi-statement-on-astrazeneca-vaccine-in-response-to-new-vaccine-safety-concerns">last night</a> the AstraZeneca vaccine <a href="https://theconversation.com/new-setback-for-vaccine-rollout-with-astrazeneca-not-advised-for-people-under-50-158661">would not be recommended</a> for people under 50. Instead, this age group will be offered the Pfizer vaccine, with the federal government today announcing it had secured an additional <a href="https://www.smh.com.au/politics/federal/australia-secures-20-million-more-doses-of-pfizer-vaccine-20210409-p57huw.html">20 million doses</a>.</p>
<p>Although details of the redesigned rollout have yet to be released, our <a href="https://medrxiv.org/cgi/content/short/2021.04.07.21255067v1">new modelling</a>, which has yet to be published in a peer-reviewed journal, shows how this might work under a range of scenarios, including the logistical requirements of different vaccines, and different vaccination venues.</p>
<p>Once a steady stream of locally manufactured AstraZeneca vaccine is available in Australia, the bottleneck in the vaccine rollout will shift from supply to administration. That’s when expanded GP vaccination clinics and mass vaccination hubs will be needed to deliver these jabs to <a href="https://urldefense.com/v3/__https:/www.health.gov.au/sites/default/files/documents/2021/01/covid-19-vaccination-australia-s-covid-19-vaccine-national-roll-out-strategy.pdf__;!!FvZmfVE!VnA8iDUVCcAFmiSpa-RUSmBBho-XUIb0heZOBl2Vxe2VBuoSfTi3OuN4YQxyKXQFUh0$">nine million people</a> over 50 in phases 1b and 2a of the rollout.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-setback-for-vaccine-rollout-with-astrazeneca-not-advised-for-people-under-50-158661">New setback for vaccine rollout, with AstraZeneca not advised for people under 50</a>
</strong>
</em>
</p>
<hr>
<h2>Here’s what we did and what we found</h2>
<p>We used mathematical simulations of waiting in line, known as stochastic queue network models, to model the process of running a vaccination clinic. </p>
<p>Queue models allow us to assess the daily vaccination capacity for different venues, taking into account available staff numbers and estimated times to complete each stage of the vaccination process.</p>
<p>The two key venues we looked at were mass vaccination hubs — which could be large venues such as halls, parks or stadiums — and GP clinics.</p>
<p>Mass vaccination hubs and GP clinics lay out their vaccine clinics differently. Hubs with larger premises and more staff can adopt an assembly line approach to vaccination. They can divide the tasks of registration, clinical assessment, vaccine preparation and administration across a series of stations. Smaller clinics are likely to have fewer people available, each performing multiple tasks. We developed two distinct models to reflect these different set-ups. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-urgently-needs-mass-covid-vaccination-hubs-but-we-need-more-vaccines-first-158416">Australia urgently needs mass COVID vaccination hubs. But we need more vaccines first</a>
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</em>
</p>
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<p>We used these models to estimate how many vaccines could be delivered in an eight-hour clinic based on a range of staffing levels, within an average overall waiting time of under an hour. </p>
<p>We estimate a small general practice could administer 100 doses, rising to 300 doses for a large practice. Mass vaccination clinics could deliver 500-1,400 doses in the same period, depending on staff numbers. </p>
<p>We also used our models to test how clinics would perform under service pressures, including increased vaccine availability and staff shortages. </p>
<p>For both delivery modes, sites with more staff were better able to keep waiting times under control as system pressures increased. Unsurprisingly, mass vaccination hubs were more robust compared to GP clinics.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-ways-australias-covid-vaccine-rollout-has-been-bungled-158225">4 ways Australia's COVID vaccine rollout has been bungled</a>
</strong>
</em>
</p>
<hr>
<h2>We can test different scenarios</h2>
<p>Our models rely on subjective assumptions about the time needed to complete different stages in the vaccination process. In reality, these timings will vary in different contexts.</p>
<p>For instance, the Pfizer vaccine <a href="https://theconversation.com/how-the-pfizer-covid-vaccine-gets-from-the-freezer-into-your-arm-155453">takes longer to prepare</a> than the AstraZeneca vaccine. Our models can account for this by increasing the expected preparation time and seeing how many extra staff would be needed to run a vaccine clinic with the same number of appointments. When the Novavax or other vaccines come on board, we can re-run the model with updated preparation times.</p>
<p>In fact, we have developed an <a href="https://cbdrh.shinyapps.io/queueSim/">an app</a> that allows anyone to re-run our simulations based on their own assumptions about service times, appointment schedules and staffing availability. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Vaccination simulator" src="https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=273&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=273&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=273&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=343&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=343&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394158/original/file-20210409-15-12ya17w.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=343&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anyone can use the app to plug in how vaccination might play out under different scenarios.</span>
<span class="attribution"><a class="source" href="https://cbdrh.shinyapps.io/queueSim/">Author supplied/UNSW</a></span>
</figcaption>
</figure>
<p>This can support policymakers, individual GPs and community pharmacies to plan vaccination delivery, as the quantity and type of available vaccine varies throughout the rollout. </p>
<p>However, there are some aspects of vaccine rollout our models do not account for. This includes essential support staff, such as administrators, cleaners and marshals.</p>
<p>Neither do our models address the logistics of distributing vaccines to vaccination centres, which is a separate challenge.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-the-pfizer-covid-vaccine-gets-from-the-freezer-into-your-arm-155453">How the Pfizer COVID vaccine gets from the freezer into your arm</a>
</strong>
</em>
</p>
<hr>
<h2>One isn’t ‘better’ than the other. We need both</h2>
<p>Our models suggest mass vaccination hubs and GP clinics are equally efficient in terms of the number of doses delivered per staff member. This supports distribution through both modes, provided GPs are enabled to vaccinate at their peak capacity. </p>
<p>These two approaches offer distinct advantages. Older people or clinically vulnerable patients may benefit from attending their local GP, who will be familiar with their medical history. </p>
<p><a href="https://www.racgp.org.au/afp/2016/april/general-practice-encounters-with-men/">Younger males</a>, busy working people and <a href="https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-020-01294-8">marginalised populations</a> are less likely to have a regular GP and may be easier to reach through mass vaccination hubs. The rollout of phase 2 to adults under 50 may require expansion of the hubs, as not all GPs may be able to store the Pfizer vaccine.</p>
<p>A diverse profile of vaccination sites, drawing on the benefits of different distribution modes, will help maximise the daily vaccination rate and vaccinate the Australian population against COVID-19 as quickly as possible.</p><img src="https://counter.theconversation.com/content/158519/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Hanly receives funding from the National Health and Medical Research Council (NHMRC) and the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE).</span></em></p><p class="fine-print"><em><span>C Raina MacIntyre has consulted for or been on advisory boards on COVID-19 vaccines for Seqirus, Janssen and Astrazeneca. She receives funding from NHMRC Principal Research Fellowship, grant number 1137582 and MRFF.</span></em></p><p class="fine-print"><em><span>Ian Caterson receives grant funding from NSW Health. He is on the board of Obesity Australia</span></em></p><p class="fine-print"><em><span>Louisa Jorm receives grant funding from the National Health and Medical Research Council (NHMRC), Medical Research Futures Fund (MRFF) and Australian Research Data Commons (ARDC). She receives funding from the Australian Government Department of Health as part of a consortium that has been commissioned to undertake an independent evaluation of the Commonwealth Health Care Homes program.</span></em></p><p class="fine-print"><em><span>Oisin Fitzgerald receives funding from the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE).</span></em></p><p class="fine-print"><em><span>Timothy Churches receives funding from the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australian Research Data Commons (ARDC) and the Ingham Institute for Applied Medical Research.</span></em></p>We’ll need mass vaccination hubs and expanded GP vaccination clinics to deliver jabs to millions of Australians.Mark Hanly, Research Fellow, UNSW SydneyC Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyIan Caterson, Medical Lead, Royal Prince Alfred Hospital COVID Vaccination Clinic, Sydney Local Health District, Boden Professor of Human Nutrition, School of Life and Environmental Sciences, University of SydneyLouisa Jorm, Director, Centre for Big Data Research in Health, UNSW SydneyOisin Fitzgerald, PhD Candidate, UNSW SydneyTimothy Churches, Senior Research Fellow, South Western Sydney Clinical School, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1541772021-02-03T03:46:50Z2021-02-03T03:46:50ZShould GPs charge for bandages or dressings? Hunt says no to ‘band-aid tax’. So here are some other options<figure><img src="https://images.theconversation.com/files/382088/original/file-20210202-15-dafd7t.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-assistant-applying-gauze-bandage-onto-623834861">from www.shutterstock.com</a></span></figcaption></figure><p>Federal Health Minister Greg Hunt recently <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">ruled out</a> GP patients having to pay for bandages and dressings, despite a major Medicare review recommending it.</p>
<blockquote>
<p>We won’t be putting in place extra charges for patients. I am ruling that out.</p>
</blockquote>
<p>Hunt was commenting on a <a href="https://www.health.gov.au/resources/publications/report-from-the-wound-management-working-group">recommendation</a> from the Medicare Benefits Schedule Review Taskforce to charge bulk-billed patients for bandages and dressings. The idea was to save patients some money at the pharmacy, where such products can be expensive. The recommendation also addressed <a href="https://medicalrepublic.com.au/wound-dressings-may-soon-to-be-covered/25714">some GPs’ concerns</a> they were out of pocket by supplying these items. However, some people <a href="https://twitter.com/SwannyQLD/status/1355669803822850052">had called</a> the recommendation to charge patients a “<a href="https://twitter.com/australiandr/status/1356090593919729670">band-aid tax</a>”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1355780810067091456"}"></div></p>
<p>Rather than charging patients, Hunt said <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">he’d discuss</a> “alternative sources of government support” for general practices and doctors to supply these items. Here are some options and what they could mean for you.</p>
<h2>A thin end of the wedge?</h2>
<p>Since 2015, the taskforce has been <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">reviewing about 5,700 items</a> on the Medicare Benefits Schedule to see which services you receive at your GP or specialist align with current evidence and practice, are safe and might benefit you.</p>
<p>Of its <a href="https://www.health.gov.au/resources/publications/medicare-benefits-schedule-review-taskforce-final-report">1,400 or more recommendations</a>, this one initially seems to be the thin end of the wedge. What would GPs charge you for next? Using equipment to take your blood pressure? The paper your bill is printed on? Luckily, separate charges for such items are <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">illegal</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-review-must-deal-with-elephant-in-the-room-incentives-40819">Medicare review must deal with 'elephant in the room' incentives</a>
</strong>
</em>
</p>
<hr>
<p>GPs can already choose to charge any amount for a consultation. And you would presume all GPs’ costs — including rent for their premises, equipment, office chairs, as well as consumables such as bandages and dressings — are considered when they decide on the level of fee to charge, or whether to bulk-bill. If the costs of supplies are increasing, then GPs can simply increase the consultation fee.</p>
<p>The recommendation also seemed inconsistent with the objectives of the review. This included trying to simplify the Medicare Benefits Schedule (not making it <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">more complicated</a>). The recommendation also seemed inconsistent with strong recommendations aimed at reducing patients’ out-of-pocket costs and making health care more affordable.</p>
<h2>What was the taskforce thinking?</h2>
<p>The taskforce argued people with chronic wounds, such as <a href="https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/leg-ulcers">venous leg ulcers</a>, often paid a lot for wound dressings they used at home.</p>
<p>Though GPs and practice nurses help dress wounds, patients still need to regularly manage and dress wounds themselves at home. So the taskforce was arguing these costs should be subsidised.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-how-do-wounds-heal-118603">Curious Kids: how do wounds heal?</a>
</strong>
</em>
</p>
<hr>
<p>The recommendation to allow GPs to charge patients was where the consultation was bulk-billed. This seemed to assume this would be cheaper for patients rather than them buying their own dressings from pharmacies and supermarkets. So the intention was to reduce out-of-pocket costs overall. </p>
<p>However, this recommendation relies on GPs charging patients less than what pharmacies or supermarkets may charge and GPs would not try to profit from selling dressings to patients. However, the taskforce presented no evidence or data to show this would be the case, even though its recommendations are supposed to be evidence-based.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bandages and dressings on supermarket shelf" src="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The taskforce thought patients could save money by going to their GP for their dressings rather than buying them at the pharmacy or supermarket.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/shah-alam-malaysia-9-june-2019-1419324386">www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Managing wounds well has both health and economic benefits</h2>
<p>Inadequate wound care can have debilitating effects and adversely influence people’s mobility and quality of life. Like any health-care treatment, keeping out-of-pocket costs low for patients can help improve access to health care and improve health outcomes. The issue is how to do this.</p>
<p>Treatment is also <a href="https://link.springer.com/article/10.1186/s12913-018-3234-3">highly cost-effective</a>. For instance, providing compression therapy products, such as compression bandages for leg ulcers, would cost the health system an additional A$270 million over five years. But it would save about $1.4 billion over the same period.</p>
<p>So it seems to make sense for new policies to try and reduce the costs GP practices and patients face for these supplies.</p>
<h2>How do we reduce the costs?</h2>
<p><strong>Centralise purchasing</strong></p>
<p>GP practices and pharmacies buy their supplies on the open market, and small GP practices may not be able to get good deals. </p>
<p>So the taskforce also recommended a Commonwealth-funded wound consumables scheme to centralise purchasing and price negotiation, as is done for medical devices and pharmaceuticals at the Commonwealth level. The idea is to keep prices low.</p>
<p><strong>Offer discounts</strong></p>
<p>Certain patients with chronic wounds could also be eligible for heavily discounted dressings from their pharmacy, though this may be difficult for less-mobile patients. GPs could “prescribe” which dressings are needed and for how long, and the pharmacies could “dispense” these for patients from the wound consumables scheme. </p>
<p><strong>Rethink dispensing</strong></p>
<p>GPs could also dispense these dressings themselves. For eligible patients who are not mobile and cannot easily visit pharmacies, GPs could provide and apply dressings for chronic wounds in the practice (or through practice nurses visiting patients at home). GPs could also provide dressings for patients to apply at home. Providing dressings at home or in the GP practice would require additional payments to general practices from Medicare.</p>
<p>This payment would need to provide incentives for GPs to manage the wounds more effectively and to buy high-quality, low-cost dressings, perhaps purchased via the wound consumables scheme.</p>
<h2>What needs to happen?</h2>
<p>For patients with chronic wounds that need long-term care (not just people wanting a band-aid), reducing the costs of bandages and dressings is likely to improve access and improve outcomes. </p>
<p>Examining the regulation of these markets could be a first step to ensure prices are as low as possible. This could include considering more centralised purchasing, followed by considering additional funding to subsidise these very cost-effective treatments.</p><img src="https://counter.theconversation.com/content/154177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding for research grants from NHMRC, ARC, and Medibank Better Health Foundation.</span></em></p>Wound care might be costly, but it’s cost-effective, saving health dollars in the long run. The issue is, who pays?Anthony Scott, Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1445062020-09-28T19:58:41Z2020-09-28T19:58:41ZSpecialist referral rules haven’t changed much since the 70s, but Australia’s health needs sure have<figure><img src="https://images.theconversation.com/files/354199/original/file-20200822-22-1k8yxpa.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C992%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vintage-gray-telephone-on-hardwood-floor-212598148">Shutterstock</a></span></figcaption></figure><p>You have a chronic health condition and visit your specialist for an annual check-up, but the referral’s expired. You’re told to get a new referral from the GP to claim the Medicare rebate. You take the next afternoon off to see your GP, who gives you another 12 month referral and tells you they can’t backdate it. You’re out of pocket for the specialist fee and gap payment for your GP consultation. You’ll have to do it all again next year.</p>
<p><a href="https://forums.whirlpool.net.au/archive/2624403">Common issues like this</a> are highlighted in a <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-brief-no-38-optimising-healthcare-through-specialist">new report</a> on the specialist referral system out today by the <a href="https://ahha.asn.au/deebleinstitute">Deeble Institute for Health Policy Research</a>, the research arm of the Australian Healthcare and Hospitals Association.</p>
<p>The report, which we co-authored, finds shortcomings in a broken referral system, plagued by <a href="https://www.aihw.gov.au/getmedia/023846dd-b30e-4149-a442-5dc0694aab26/aihw_phc_1.pdf.aspx">poor data</a> collection and wasted dollars.</p>
<p>Fixing these issues requires a better understanding of patients’ long-term needs and the health and economic consequences of the medical referral system. </p>
<h2>Chronic illness is more common now</h2>
<p>The rules about specialist referrals were developed in the <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;adv=yes;orderBy=_fragment_number,doc_date-rev;page=0;query=%22referral%20system%22%20%221970%22%20Decade%3A%221970s%22%20Year%3A%221970%22;rec=0;resCount=Default">70s</a>, when acute illness was <a href="https://www.racgp.org.au/FSDEDEV/media/documents/Special%20events/Health-of-the-Nation-2019-Report.pdf">more common</a>.</p>
<p>Now <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview">more people</a> each year are being diagnosed with a chronic illness, needing long-term specialist management.</p>
<p>They will often need multiple referrals, depending on how many specialists they see and when these referrals expire. This can be a <a href="https://chf.org.au/sites/default/files/chf_submission_to_mbs_review_final.pdf">frustrating</a> financial and logistical burden and can even cause some patients to delay treatment.</p>
<h2>Referrals can be too short</h2>
<p>Different types of health-care workers <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s96.html">can refer</a> you to specialists or consultant physicians. The duration of the referral ultimately <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s102.html">depends on who issues it</a>.</p>
<p>GPs commonly limit their referrals to <a href="https://www.racgp.org.au/FSDEDEV/media/documents/Running%20a%20practice/Practice%20resources/Referring-to-other-medical-specialists.pdf">fixed terms</a>, even though <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/hir2018273/s102.html">indefinite referrals</a> are possible. Specialists can only issue referrals to other specialists for three months, and this rule poses serious challenges for many vulnerable people.</p>
<figure class="align-center ">
<img alt="A doctor handing a patient a referral letter" src="https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360192/original/file-20200928-24-jcrbie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">GPs can issue referrals with no time limit, but rarely do.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/19F237413A9086B6CA2580180019C0C4/$File/MBS-Review-Taskforce-Recommendations-Principles-and-Rules-Report.pdf">One example</a>, taken from a review of Medicare in 2016, is of cancer patients receiving different types of therapy, where the radiation oncology treatment lasts longer than three months. When the referral expires, the patient needs to obtain a new one to continue treatment.</p>
<p>Issues the review <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/19F237413A9086B6CA2580180019C0C4/$File/Final%20first%20report%20of%20the%20MBS%20Principles%20and%20Rules%20Committee.pdf">identified</a> about the three month rule included difficulties providers had in interpreting the rules, leading to improper Medicare billing practices. This echoes <a href="https://www.abc.net.au/news/2014-05-13/annual-specialist-referrals-wasting-millions,-say-gps/5447822?nw=0">previous concerns</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
</strong>
</em>
</p>
<hr>
<h2>Why are referrals stuck in the 70s?</h2>
<p>Regardless of the burden on patients, health-care workers and Medicare, both sides of government have shown little interest in changing the referral rules. </p>
<p>This is largely because of the general principles that sit behind them. These include the need to keep people away from expensive specialist care and the importance of <a href="http://www5.austlii.edu.au/au/legis/cth/num_reg_es/hir2018201801365289.html">GPs as gatekeepers</a> of the health system.</p>
<p>So, the purpose of a referral is to provide access to Medicare subsidies for specialist care. But the purpose of a referral expiring is actually to reconnect you with your GP, who then issues a new referral if you are receiving ongoing specialist care.</p>
<p>The referral system offers important economic benefits. But the burden of referral expiration and the limited referral pathways available for patients needs attention. Revising how referrals operate and improving the system of communication between care teams can overcome many associated challenges.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
</strong>
</em>
</p>
<hr>
<h2>The referral system doesn’t always give good value</h2>
<p>We’re seeing a trend toward what’s called <a href="https://valuebasedcareaustralia.com.au/about/governance/">value-based care</a>. This is the idea <a href="https://grattan.edu.au/wp-content/uploads/2016/03/936-chronic-failure-in-primary-care.pdf">GPs</a> and <a href="https://evolve.edu.au/">specialists</a> should deliver effective and efficient patient care, taking into account the limited resources available.</p>
<p>But the current referral system can discourage this.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/7-lessons-for-australias-health-system-from-the-coronavirus-upheaval-141122">7 lessons for Australia's health system from the coronavirus upheaval</a>
</strong>
</em>
</p>
<hr>
<p>A recent example of the misuse of referrals is with Victoria’s <a href="https://www.dhhs.vic.gov.au/call-to-test-covid-19">Call-to-Test</a> program for COVID-19. This is designed to provide <a href="https://www.abc.net.au/news/2020-08-11/how-victorias-home-coronavirus-testing-will-work/12541296">about 200</a> vulnerable Melburnians access to nurse-led in-home COVID-19 testing each day. </p>
<p>People need a GP referral, unlike most government-run COVID-19 clinics around Australia. Victoria’s health department <a href="https://www.dhhs.vic.gov.au/call-to-test-covid-19#do-i-need-a-general-practitioner-gp-referral">says</a> a referral is needed so test results can be incorporated into treatment plans.</p>
<figure class="align-center ">
<img alt="A medicare card" src="https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360193/original/file-20200928-18-5v1y9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is strong support from both consumers and health-care workers for improving the referral system.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>But referrals, as a vehicle, don’t achieve this. Referrals relate to Medicare billing and they are not designed to facilitate GP follow-up care.</p>
<p>We estimate GP consultations to obtain the Call-to-Test referrals are likely to cost Medicare anywhere from A$10,300 a day (if GPs claim for a <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=91800&qt=ItemID#:%7E:text=91800%20%2D%20Additional%20Information&text=(c)%20implementing%20a%20management%20plan,providing%20appropriate%20preventative%20health%20care.&text=(b)%20the%20service%20must%20be,service%20may%20be%20bulk%2Dbilled._">shorter consultation</a> along with a <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/0C514FB8C9FBBEC7CA25852E00223AFE/$File/FAQ%20-%20COVID-19%20Bulk%20Billing%20Incentive%20-%20080520.pdf">bulk billing incentive</a>) up to a $17,560 a day (if GPs claim for a <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=91801&qt=item&criteria=91801">longer consultation</a>). This would be on top of the cost of any follow-up services after the test results are known, which is where the money is better spent.</p>
<h2>If not now, when?</h2>
<p>Rather than waiting until the next scheduled review of the <a href="https://www.legislation.gov.au/Details/F2020C00656">referral rules</a> in 2028, we can do better, sooner. There is strong <a href="https://chf.org.au/sites/default/files/chf_submission_to_mbs_review_final.pdf">consumer</a> and <a href="https://australian.physio/sites/default/files/submission/Submission_PreBudget_2015-16.pdf">clinician</a> support for a more efficient referral system. </p>
<p>Key legislative changes we’d like to see include expanding referral pathways and giving specialists the flexibility to extend referrals when needed, rather than letting them expire. </p>
<p>Consumer awareness of their referral rights is also needed. So too is compulsory and ongoing training for Medicare Benefit Schedule providers, administrators and Medicare staff who advise practitioners of the rules.</p>
<p>Supporting all of this, we need an independent inquiry and further research to ensure evidence-informed policies guide high-value, cost-effective care within the referral system.</p><img src="https://counter.theconversation.com/content/144506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christie M. Gardiner co-authored the report mentioned in this article but received no external funding for this. She does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Rebecca Haddock co-authored this article and the report mentioned in it. Rebecca is the director of the Deeble Institute for Health Policy Research, the research arm of the Australian Healthcare and Hospitals Association.</span></em></p><p class="fine-print"><em><span>Samantha Prime co-authored the report mentioned in this article, and was supported as a Deeble Institute for Health Policy Research Summer Scholar 2020 by the Australian Healthcare and Hospitals Association and HESTA.</span></em></p>Many more people need long-term specialist care, or are waiting a long time for elective surgery. These and other factors tell us we need to update how specialist referrals work.Christie M. Gardiner, Associate Lecturer of Law, University of NewcastleSamantha Prime, PhD Candidate | Health Policy, Systems & Services, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1435932020-07-29T04:06:49Z2020-07-29T04:06:49ZWhy is the government restricting Medicare funds for ECGs when expert advice says exactly the opposite?<figure><img src="https://images.theconversation.com/files/350087/original/file-20200729-19-3zeqde.jpg?ixlib=rb-1.1.0&rect=0%2C147%2C4108%2C2545&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>From August 1, if the federal government has its way, Medicare will <a href="https://www.abc.net.au/news/2020-07-28/medicare-changes-to-heart-procedures-could-hamper-patient-care/12496894">stop paying</a> for GPs to interpret common heart tests called electrocardiograms, or ECGs.</p>
<p>Health Minister Greg Hunt says the decision is based on safety advice from a top-level medical expert panel convened by the government to review Medicare rebates. But a closer look at the advice reveals the panel suggested precisely the opposite.</p>
<p>And by treating ECG interpretation as a specialised task rather than an everyday part of a GP’s toolkit, the change risks making it harder and more expensive for patients to access these simple but potentially life-saving tests.</p>
<h2>What are ECGs?</h2>
<p><a href="https://www.healthdirect.gov.au/electrocardiogram-ecg">ECGs</a> are tracings of the heart’s electrical activity. If you’ve watched a medical drama on TV and seen a flat line on a screen bounce back to a healthy wobbly line as a patient is rescued from cardiac arrest, you’ve seen an example of an ECG – it’s that wobbly line.</p>
<p>In fact, ECGs in real life typically consist of 12 different wobbly lines (a so-called “12-lead ECG”), as the heart’s electrical activity is measured from different directions. If you’ve had one yourself, you may remember sticky patches being placed on your skin, and a tangle of wires connecting these patches to a special machine that prints out the ECG trace.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/your-apple-watch-can-now-record-your-ecg-but-what-does-that-mean-and-can-you-trust-it-103430">Your Apple Watch can now record your ECG – but what does that mean and can you trust it?</a>
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<p>These tests are a common tool for many doctors, including GPs. All medical students are expected to learn to interpret an ECG – it is not a test reserved for cardiologists.</p>
<p>There are all sorts of situations in which a GP may need to use and interpret an ECG. One obvious example is when a patient is suffering chest pain that could be due to a <a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">heart attack or angina</a>. Others include assessing unusual heart rhythms, such as <a href="https://theconversation.com/getting-to-the-heart-of-the-matter-on-stroke-7180">atrial fibrillation</a>, which is a common and important risk factor for stroke that <a href="https://www1.racgp.org.au/ajgp/2019/october/atrial-fibrillation">GPs are encouraged to detect and treat</a>.</p>
<p>ECGs are so fundamental that Australian general practices <a href="https://www.racgp.org.au/running-a-practice/practice-standards/standards-5th-edition/standards-for-general-practices-5th-ed">are required to demonstrate “timely access” to an ECG machine</a> as part of their accreditation.</p>
<h2>What is the government proposing?</h2>
<p>Medicare has for many years <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=11700&qt=item&criteria=11700">funded the tracing and reporting of ECGs</a> in general practice. The government <a href="https://www1.racgp.org.au/newsgp/professional/gps-call-out-ridiculous-changes-to-cardiac-imaging">is now proposing to remove funding</a> of the reporting of ECGs from GPs. Funding for interpretation or reporting of ECGs will be restricted to specialists.</p>
<p>Under the new plan, public funding for ECGs in general practice will be restricted to producing (rather than interpreting) the trace. This is a technical task rather than a medical one, and many GPs, who rightly feel qualified to interpret ECGs, <a href="https://www1.racgp.org.au/newsgp/professional/gps-call-out-ridiculous-changes-to-cardiac-imaging">find this insulting</a>.</p>
<p>More importantly, this loss of funding may harm patients. As shadow health minister Chris Bowen <a href="https://www.abc.net.au/news/2020-07-28/medicare-changes-to-heart-procedures-could-hamper-patient-care/12496894">has explained</a>, an increase in out-of-pocket costs to patients, or a reduction in funding to general practice, may limit availability of this important test to people who need it. There is <a href="https://theconversation.com/six-dollar-co-payment-to-see-a-doctor-a-gps-view-21915">good evidence</a> out-of-pocket costs limit access to health care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/six-dollar-co-payment-to-see-a-doctor-a-gps-view-21915">Six dollar co-payment to see a doctor: a GP's view </a>
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<p>While traces can be forwarded to a cardiologist for interpretation, this too may involve costs, and may be difficult in rural and remote areas.</p>
<h2>The health minister’s explanation doesn’t stack up</h2>
<p>Pressed to justify these proposals, health minister Greg Hunt this week <a href="https://www.theguardian.com/australia-news/live/2020/jul/28/coronavirus-australia-victoria-aged-care-outbreak-melbourne-sydney-nsw-qld-andrews-berejiklian-morrison-latest-updates?CMP=share_btn_tw&page=with:block-5f1f4d798f080665365e6caf#block-5f1f4d798f080665365e6caf">told the ABC</a>:</p>
<blockquote>
<p>This came from a medical expert panel. It came from what’s known as the Medicare taskforce, led by Prof Bruce Robinson. It’s the highest clinical advice and it was based on safety.</p>
</blockquote>
<p>A Department of Health spokesperson <a href="https://www.abc.net.au/news/2020-07-28/medicare-changes-to-heart-procedures-could-hamper-patient-care/12496894">offered a similar line</a> to the ABC in a news article this week.</p>
<p>The taskforce (formally called the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">Medicare Benefits Schedule Review Taskforce</a>) has been working to reform the Medicare schedule – that is, the list of medical services funded by Medicare. This is a fine initiative, which brings evidence and expertise to the task of modernising Medicare. Appropriately, it enjoys the bipartisan support of our major parties. It is laudable when the government follows such independent expert advice.</p>
<p>The problem here is that, contrary to Hunt’s claim, the MBS Review Taskforce did not recommend that Medicare stop paying for GPs to interpret ECGs. On the contrary, the taskforce explicitly recommended the opposite. </p>
<p>The <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/F9DA276B6A541A82CA2581C2006F875C/$File/MBS%20Review%20Taskforce%20Recommendations%20-%20Cardiac%20Services%20Report%20PDF%20version.pdf">344-page final report of the taskforce’s Cardiac Services Clinical Committee</a> is pretty dry reading, but if you make it as far as page 200 you’ll find it acknowledges the importance of ECGs in general practice. In fact, the report explicitly proposes a new Medicare rebate to “allow all practitioners to take and interpret an ECG when clinically required”.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Screenshot of a section of the report" src="https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=171&fit=crop&dpr=1 600w, https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=171&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=171&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=215&fit=crop&dpr=1 754w, https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=215&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/350076/original/file-20200729-15-1moearw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=215&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The taskforce’s heart committee recommended Medicare funding all practitioners to take and interpret ECGs.</span>
<span class="attribution"><a class="source" href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/F9DA276B6A541A82CA2581C2006F875C/$File/MBS%20Review%20Taskforce%20Recommendations%20-%20Cardiac%20Services%20Report%20PDF%20version.pdf">Dept of Health</a></span>
</figcaption>
</figure>
<p>Instead, the federal government has proposed an <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/17C7BC57C362E844CA258591000B2432/$File/Quick%20Reference%20Guide%20-%20Changes%20to%20cardiac%20ECG%2020620.pdf">array of new ECG rebates</a>, none of which would fund GPs to interpret ECGs.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
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<p>Granted, health policy is a complex area, even when there isn’t a pandemic unfolding. Nevertheless, this seems to be a clear case of expert advice not being translated into policy.</p>
<p>I would urge Hunt and his department to heed the advice of their own expert taskforce, and the concerns raised on behalf of GPs and their patients, and reverse their plans to defund ECG interpretation in general practice – or at least offer a full explanation as to why they are proceeding with this policy.</p><img src="https://counter.theconversation.com/content/143593/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brett Montgomery works as a general practitioner, mostly academically but also clinically. In his clinical role he and his patients benefit from Medicare funding of his interpretation of ECGs. He is affiliated with several organisations with health policy interests, including the Royal Australian College of General Practitioners, the Doctors Reform Society and the Australian Greens. However, he writes this article in a personal capacity.</span></em></p>Electrocardiograms are a common tool used by GPs to spot heart problems, and every medical student is trained to interpret one. Yet the government plans to remove Medicare funding for GPs to do this.Brett Montgomery, Senior Lecturer in General Practice, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1329952020-03-05T16:09:23Z2020-03-05T16:09:23ZAre autistic personality tests reliable?<figure><img src="https://images.theconversation.com/files/318872/original/file-20200305-106610-1gtsdsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-pen-over-application-form-315241841">Shutterstock/jannoon028</a></span></figcaption></figure><p>Autism has been a subject of ever increasing interest over the last 20 years. It has been the subject of popular TV shows, novels and numerous studies looking at everything from sensory experiences to mental health in autism. As a result, there is a growing need for efficient and reliable ways to measure autism levels.</p>
<p>The most popular way of doing this is by using questionnaires of autism personality traits. There are several tests available, in which participants are asked to rate how much they agree with statements like “I find it easy to work out what someone is thinking or feeling just by looking at their face” and “I find it difficult to work out people’s intentions”.</p>
<p>These tests are routinely used by doctors and researchers. This is partly because they can be completed quickly, enabling efficient clinical assessment and allowing people to take part in autism research without too much hassle. The tests are also <a href="https://psychcentral.com/quizzes/autism-test/">found online</a> and used by people to understand autistic traits, but they are sometimes <a href="https://www.autism.org.uk/about/diagnosis/adults.aspx">mistaken as diagnostic tools</a>. </p>
<p>In research, autism personality trait measures are commonly used to investigate autistic traits in the population and whether or not they relate to other psychological traits. Recently, for example, autism personality trait tests were used to investigate how autism <a href="https://link.springer.com/article/10.1007/s10803-019-04080-3">relates to empathy in the general population</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/autism-is-linked-to-lower-levels-of-empathy-but-that-may-not-be-a-bad-thing-118359">Autism is linked to lower levels of empathy – but that may not be a bad thing</a>
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<p>One common questionnaire – used by doctors and researchers – is the “<a href="https://www.sciencedirect.com/science/article/pii/S0890856711010331">10-item autism-spectrum quotient (AQ-10)</a>”. The AQ-10 comprises ten statements like those mentioned above, with participants asked to state how much they agree or disagree. </p>
<p>The UK’s National Institute for Health and Care Excellence (Nice), a government body that gives guidance to the NHS, recommends the AQ-10 as a screening tool for autism in adults. It is also widely used in online <a href="https://www.pnas.org/content/116/39/19245">psychological</a> and <a href="https://molecularautism.biomedcentral.com/articles/10.1186/s13229-019-0308-y">clinical</a> research.</p>
<p>But despite the popularity of the AQ-10 test, little research has been done to find out if the test has good “psychological reliability”. This can be measured by seeing how well the questions in the test are linked to each other and by testing whether it is measuring one thing – autism – or just a mix of several different things, such as empathy and attention to detail. </p>
<p>To address these questions, a <a href="https://doi.org/10.1017/exp.2019.3">new study</a> by <a href="https://www.punitqshah.com/">our research group</a> analysed responses to the AQ-10 from over 6,500 people who had completed the test online.</p>
<h2>Improvement needed</h2>
<p>Using advanced statistical analyses, we found that the AQ-10 lacks reliability as a measure of autism personality traits. Most of its questions did not hang well together, which is not ideal as the total scores are being used in research. Additional analyses suggested that the test was possibly measuring several psychological processes and behaviours – not just autism. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318876/original/file-20200305-106573-17prdm7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A fresh look at diagnosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/autism-printed-diagnosis-blurred-text-on-481851856">Shutterstock/Tashatuvango</a></span>
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</figure>
<p>The results of the study raise questions about whether it is appropriate to use the AQ-10. It might be useful as a screening tool for doctors, but researchers should examine its reliability when using it in future. The public should also be careful when completing online autism personality tests, which may be unreliable, outdated and misleading. </p>
<p>Our findings contribute to a growing awareness that many psychological methods <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450842/">used in autism research need to be improved</a>. We analysed just one of many autism questionnaires. It is clear that we need more studies to see if other autism tests have similar issues. </p>
<p>This is important because issues with autism personality tests may be slowing down research, confusing doctors and misleading the public about autism. It is crucial that we continue doing research to study and refine autism personality questionnaires, which will be important for the continued improvement in understanding and supporting people with autistic traits and diagnosed autism in society.</p><img src="https://counter.theconversation.com/content/132995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Clutterbuck receives funding from the Economic and Social Research Council. </span></em></p><p class="fine-print"><em><span>Emily Taylor receives funding from a Whorrod Doctoral Scholarship.</span></em></p><p class="fine-print"><em><span>Punit Shah receives funding from the Medical Research Council and the Economic and Social Research Council</span></em></p>We found that one of the most widely used tests does not come up to scratch.Rachel Clutterbuck, PhD Candidate, University of BathEmily Taylor, PhD Candidate, University of BathPunit Shah, Assistant Professor (Lecturer) in Psychology, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1262272019-11-26T10:48:57Z2019-11-26T10:48:57ZSome patients with suspected cancer fail to attend referral appointments – we found out why<figure><img src="https://images.theconversation.com/files/302938/original/file-20191121-524-1krwo71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/digital-render-three-chairs-plant-pot-29094811?src=334082c3-9420-4e2f-8942-51d33c523874-1-75">Oliver Klimek/Shutterstock</a></span></figcaption></figure><p>If a patient has signs or symptoms of cancer, a GP would refer him or her to a specialist. You might think every patient suspected of having cancer would be sure not to miss this visit to an oncologist, but our latest research shows that <a href="https://www.sciencedirect.com/science/article/pii/S1877782119300992#bibl0005">more than 5%</a> of patients cancel or don’t turn up for these crucial appointments. An appointment could confirm cancer, but equally, it could rule it out. </p>
<p>We found that patients who didn’t attend these appointments (let’s call them non-attending patients) were less likely than attending patients to be diagnosed with cancer. (All cancers in the UK are registered, which is how we know about cancers in patients who attended the initial appointment and later in those who didn’t.) But non-attending patients who were eventually diagnosed with cancer were 12% more likely to die <a href="https://www.sciencedirect.com/science/article/pii/S1877782119300992">within a year of receiving a diagnosis</a>.</p>
<p>Non-attending patients tended to have more advanced disease when their cancer was confirmed, suggesting they had been slower to make the GP appointment that <a href="https://www.nature.com/articles/bjc201549">resulted in a referral to a specialist</a>. </p>
<h2>Better outcomes</h2>
<p>Cancer outcomes in the UK have improved greatly over recent decades. <a href="https://webarchive.nationalarchives.gov.uk/20160107053639/http:/www.ons.gov.uk/ons/rel/cancer-unit/cancer-trends-in-england-and-wales/smps-no--66/index.html">People with cancer</a> now live longer and have a greater chance of the disease being successfully treated. These <a href="https://www.nature.com/articles/bjc201549">improvements</a> are because treatments are better and cancers are being found and diagnosed sooner.</p>
<p>In the UK, <a href="https://www.sciencedirect.com/science/article/pii/S0959804913000889">quicker cancer diagnoses</a> have happened partly through shortening the time between patients’ first report of symptoms and the diagnosis being made. In 2000, the <a href="https://www.thh.nhs.uk/documents/_Departments/Cancer/NHSCancerPlan.pdf">NHS introduced a two-week-wait policy</a> which, as the name suggests, aimed to ensure that people who may have cancer are seen by a specialist within <a href="https://www.england.nhs.uk/wp-content/uploads/2015/03/delivering-cancer-wait-times.pdf">two weeks of a GP referral</a>.</p>
<p>The UK’s National Institute for Health and Care Excellence (NICE) <a href="https://www.nice.org.uk/guidance/ng12">recently changed</a> the two-week-wait policy, lowering the threshold at which a GP should refer a patient to a cancer specialist. For example, under the new guidelines, GPs should now refer patients aged over 40 with unexplained weight loss and abdominal pain, thereby increasing the referral of more patients with non-specific symptoms that could be cancer. </p>
<p>In England there are now <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2017/06/Cancer-Waiting-Times-Annual-Report-201617-1.pdf">1.9 million two-week-wait referrals</a> each year and <a href="https://fingertips.phe.org.uk/profile/cancerservices/data#page/0/gid/1938133085/pat/46/par/E39000030/ati/153/are/E38000010">48% of all cancers</a> in the UK are diagnosed through this route. Most other cancers are identified through emergency hospital admission or screening. </p>
<p>Lowering referral thresholds has identified more cancers - the planned outcome – but it has also reduced the chance that a referred patient will actually have cancer. The rate of cancer diagnosis <a href="https://fingertips.phe.org.uk/profile/cancerservices/data#page/0/gid/1938133085/pat/46/par/E39000030/ati/153/are/E38000010">is 9% among patients</a> referred under two week wait, which means that GP referrals are used to <em>rule out</em> cancer in most patients. </p>
<p>Lowering the cancer referral threshold creates two problems. First, more patients having a period of worry between GP referral and the hospital appointment. Second, for GPs, <a href="https://www.nature.com/articles/bjc201541">the difficult task of communicating</a> two pieces of potentially conflicting information to patients. One, that the referral is important, and two, that most referred patients will not have cancer.</p>
<p>Our research into patients who don’t attend their hospital appointment comprised a statistical study of more than <a href="https://www.sciencedirect.com/science/article/pii/S1877782119300992">100,000 patients who’d received an urgent referral for suspected cancer</a>, and an <a href="https://bjgp.org/content/early/2019/11/19/bjgp19X706625">interview study</a> with GPs and with patients who had cancelled or not attended their urgent referral appointment.</p>
<h2>Reasons for not attending</h2>
<p>Our statistical analysis showed that people who were least likely to attend their hospital appointment were men, the very young and the very old, patients with particular types of suspected cancer (especially gastro-intestinal cancer), people living far from the hospital, and people from poorer parts of the city.</p>
<p>The interviews revealed several reasons for not attending appointments. They included patients having several health problems or many other competing demands, patients finding it difficult to navigate the appointment system, <a href="https://journals.sagepub.com/doi/full/10.1177/0969141316645629">being afraid of the diagnosis</a>, and expecting diagnostic tests to be unpleasant or <a href="https://www.nature.com/articles/bjc2015176">embarrassing</a>. And, surprising as it may seem, some people didn’t see a possible cancer diagnosis as the most important thing in their lives.</p>
<p>All cancers, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883152/">except for melanoma</a>, are more common in <a href="https://link.springer.com/article/10.1007/s10552-008-9256-0">lower-income groups in the UK</a>. People from <a href="https://www.nature.com/articles/6605752">higher income groups</a> also live longer after cancer is diagnosed. Poverty affects health behaviour in different ways, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61690-6/fulltext">both directly</a> (for example, not having enough money to pay for a prescription) <a href="https://www.penguin.co.uk/books/188/188607/the-inner-level/9780141975399.html">and indirectly</a> (for example, valuing your life less than other people’s). Many practical, financial and health demands on lower-income patients <a href="https://bmjopen.bmj.com/content/5/4/e006965">can influence</a> how important they see the hospital appointment to be.</p>
<p><a href="https://www.sciencedirect.com/science/article/abs/pii/S0033350616000044">Health literacy</a> may also explain non-attendance. Health literacy is a person’s ability to find, understand and use health information and healthcare systems. It has become <a href="https://www.who.int/healthpromotion/conferences/9gchp/health-literacy/en/">highly influential</a> over the past 20 years. For example, health literacy is a <a href="https://www.bmj.com/content/344/bmj.e1602.full">predictor of life expectancy</a> in older people.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/302951/original/file-20191121-502-3om7e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health literacy is key.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/343216736?src=be1121e0-3f60-4f5d-a235-ecbcc0e2abaf-1-1&size=medium_jpg">Speedkingz/Shutterstock</a></span>
</figcaption>
</figure>
<p>Our research suggests it may play an important role in urgent referral appointments, with patients with lower levels of health literacy delaying seeing their GP about <a href="https://cebp.aacrjournals.org/content/19/9/2272.short">their symptoms</a>, or finding it difficult to use the hospital appointments system, or <a href="https://www.nature.com/articles/6605398">not understanding</a> the importance of the urgent referral hospital appointment.</p>
<p>Patients failing to attend urgent referral appointments have caused great concern among GPs and hospital staff, partly about the cost of wasted staff time, but also because of the health of these patients, who had symptoms when the GP referred them. </p>
<p>We need to find solutions to this important problem, such as GPs ensuring that patients understand the appointments system and the importance of attending, and reassuring patients about possible diagnostic tests. Contacting and re-booking non-attenders must also be a priority. </p>
<p>A greater challenge is to ensure that patients don’t delay reporting symptoms to their GP. Our research suggests that patients who delay may be at greater risk of not attending their hospital appointment, so GPs could stress the importance of attendance in those patients especially.</p>
<p><em>Correction. An earlier version of this article stated that “non-attending patients who were eventually diagnosed with cancer were 12% more likely to die from cancer within a year of receiving a diagnosis”. It should have read: “But non-attending patients who were eventually diagnosed with cancer were 12% more likely to die within a year of receiving a diagnosis.”</em></p><img src="https://counter.theconversation.com/content/126227/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Two Week Wait study was funded by a grant from the charity Yorkshire Cancer Research. Peter Knapp also receives funding from the UK National Institute for Health Research; the Academy of Medical Sciences; and the Health Research Board of Ireland. </span></em></p>One in 20 patients referred to a cancer specialist by their GP don’t turn up.Peter Knapp, Reader in Health Sciences, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111292019-02-22T14:28:40Z2019-02-22T14:28:40ZI had whooping cough as a GP trainee – the experience informed my academic work and clinical practice<figure><img src="https://images.theconversation.com/files/258297/original/file-20190211-174887-50c7l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1295474197?src=hlnCEnESYS3O-KiZ5WYmjg-2-79&size=medium_jpg">Aaron Amat/Shutterstock</a></span></figcaption></figure><p>During my first year of training to be a GP, I developed a dry cough. I coughed in fits and at the end of a fit, I felt sick. It interrupted my sleep and taking over-the-counter painkillers and natural remedies, such as turmeric, honey and lemon, did little to ease my symptoms.</p>
<p>As doctors make the worst patients, I gave up and succumbed to my family’s nagging and went to see my GP. He took a history and examined me. He gave me antibiotics for a suspected bacterial chest infection and an inhaler for the wheeze he heard in my chest. The inhaler was odd since I was not asthmatic. </p>
<p>The cough was interrupting my sleep and I had to take time off work. After four days, the inhaler and antibiotics were doing very little, so I saw another GP who asked: “What would you do as a trainee GP if someone came to you after just four days of using the antibiotics you prescribed?” The suggestion being that I should have waited longer for the drugs to take effect rather than bother him with another appointment. </p>
<p>It was humiliating to be treated like a student, especially by a fellow doctor. But I could see why the GP was annoyed. He assumed that I had a bacterial infection of the upper airways, and sometimes coughs can last for several weeks after a full course of antibiotics (it’s what’s known as a “post-infectious cough”). But my cough was related to a different kind of bacteria to the one I was being treated for.</p>
<p>I was offered a different inhaler. Later that day I received a call from the GP who suggested I might have whooping cough. This was presumably after the lunchtime meeting where GPs discuss cases from the morning. It must have been puzzling how a GP trainee who rarely visits his GP would suddenly request to be seen twice in one week. The GP suggested a blood test, but wasn’t sure what else he could do. My blood test was positive for whooping cough. I received antibiotics but not before passing on this bacterial infection to two family members. </p>
<p>A couple of months later, coincidentally, we had a GP-led teaching session on whooping cough and several GP trainees thought they had cases that matched the symptom profile. But the sources online (from <a href="https://cks.nice.org.uk/whooping-cough#!diagnosis">NICE</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/762766/Guidelines_for_the_Public_Health_management_of_Pertussis_in_England.pdf">Public Health England</a>) were difficult to grasp, so I decided to write <a href="https://www.bmj.com/content/364/bmj.l401.full">an article</a> for the BMJ with up-to-date, accessible guidance for healthcare professionals.</p>
<p>As a clinical academic, I often find that my academic work is inspired by questions that arise from my clinical work, but I never thought I would be the patient from whom I would draw inspiration to change clinical practice.</p>
<h2>A guide for readers</h2>
<p>Whooping cough or pertussis is an infection caused by the bacteria <em>Bordetella pertussis</em>. The cough gets its name from the whooping gasps a person makes as they try and catch their breath between bouts of coughing. </p>
<p>People can get whooping cough at any age, but children under the age of six months have a higher risk of complications (including death), which may be due to their immature immune systems and the fact that they haven’t finished the course of immunisation against the disease at this point. </p>
<p>It can affect adults, too, especially those who have existing respiratory problems. The risk of getting whooping cough is also higher in adults who are overweight or obese, or those who have a weak immune system.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/31tnXPlhA7w?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Here’s what it sounds like.</span></figcaption>
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<p>Being vaccinated against the disease is no guarantee of protection, especially up to a decade after your last vaccine, which is why some countries suggest having boosters. </p>
<p>Although the vaccines are only short-lasting, pregnant women can protect their newborns by being immunised. A recent <a href="https://jmm.microbiologyresearch.org/content/journal/jmm/10.1099/jmm.0.000829#tab2">review article</a> concluded that the vaccine is both safe for mothers and effective for babies.</p>
<p>Symptoms of whooping cough include coughing several times in a row (paroxysms or fits), gasping (“whooping”) between coughing paroxysms and vomiting after coughing. In babies, it can also include intermittently stopping breathing. Treating whooping cough promptly with antibiotics won’t stop the prolonged symptom course of coughing – often called the “100 day cough” – but it can stop the disease spreading, especially to vulnerable groups, such as young babies.</p><img src="https://counter.theconversation.com/content/111129/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dipesh Gopal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Whooping cough is making a comeback. Here’s how to identify it, and why vaccination is a way to protect babies.Dipesh Gopal, Academic Clinical Fellow, General Practice, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1006842018-09-06T11:16:27Z2018-09-06T11:16:27ZPenicillin was discovered 90 years ago – and despite resistance, the future looks good for antibiotics<figure><img src="https://images.theconversation.com/files/229603/original/file-20180727-106524-l87kc3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>When the <a href="https://theconversation.com/the-nhs-explained-in-eight-charts-91854">NHS turned 70</a> this year, I was reminded of another anniversary which has had an enormous impact on healthcare over many years. Penicillin is 90 this year. </p>
<p>Discovered in September 1928 by <a href="http://www.bbc.co.uk/history/historic_figures/fleming_alexander.shtml">Alexander Fleming</a>, it was first used as a cure when George Paine treated eye infections with it in 1930. A method for mass production was devised by Howard Florey and Ernst Chain in 1940, and it was first mass produced in 1942, with half of that total supply used for one patient being treated for streptococcal septicaemia. </p>
<p>In 1944, 2.3m doses were produced in time for the <a href="https://theconversation.com/the-military-power-economics-and-strategy-that-led-to-d-day-27663">Normandy landings</a> of World War II. And it was then that the miracle of penicillin became clear. Soldiers who had previously died from septicaemia were surviving.</p>
<p>Expectations rose. If penicillin could cure septicaemia, what about other serious infections like meningitis, pneumonia and kidney infections? Of course, we should use it for these, too. And what about nasty chest infections and troublesome sinusitis? Or inconvenient sore throats which could affect wedding days or job interviews – should these be treated with penicillin?</p>
<p>It seems (and for good reason) that we all wanted to be part of the 20th-century miracle that was penicillin. Patients didn’t want to be patients and doctors wanted to cure – why else did we come into medicine? </p>
<p>So antibiotic use grew and grew – and grew. Today, tens of millions of prescriptions are written in the UK every year, mostly by GPs and nurses in primary care. </p>
<p>But all is not well. Fleming was aware of the problem as soon as he discovered penicillin. Most bacteria were killed by the medicine, but others were immune, somehow able to resist the miracle. </p>
<p>And here is the paradox – in contrast to most medicines, the more we use antibiotics, the less effective they become. It’s because the bacteria multiply so rapidly – some every 20 minutes. If any one of the bacteria happens to survive antibiotic treatment, so do all of their offspring. And the antibiotic gives an immediate survival advantage to the resistant bacteria by indiscriminately destroying the competition. </p>
<p>The resistant bacteria affect us – our infections and hospital admissions last longer and are more expensive to treat. Over 25,000 people die every year from antibiotic-resistant infections in the UK and Europe. </p>
<p>But there is hope. There has been a massive, coordinated effort by the UK government, chief medical officers, NHS policy makers, NICE, the pharmaceutical industry, GPs, nurses, patients and academics. And <a href="https://theconversation.com/its-the-age-of-the-antibiotic-revolution-not-apocalypse-73476">we are making progress</a>. We have just witnessed <a href="https://www.england.nhs.uk/2016/03/antibiotic-prescribing/">the first reduction</a> (over 5%) in antibiotic prescribing in primary care for several years. </p>
<h2>Working with patience</h2>
<p>As a GP and professor of primary care who has observed the problem of antimicrobial resistance for over 20 years, I am optimistic about the future. More of my patients have heard about antibiotic resistance and seem to take it seriously. We all want to steward this precious resource for the next generation and I believe we will rise to the challenge. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229601/original/file-20180727-106530-mtzziv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A plaque at St Mary’s Hospital in London.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-february-13-plaque-commemorating-discovery-185229575?src=z6hOzyS7QtRbZrdUIJLMVQ-1-91">Shutterstock</a></span>
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<p>At the University of Bristol’s <a href="http://www.bristol.ac.uk/primaryhealthcare/researchthemes/disease-management/infection.html">Centre for Academic Primary Care Infection Group</a>, we continue to ask the big questions: why do some people experience lots of infections and others very few? How can we protect ourselves from acquiring infections in the first place? And are there effective alternatives to antibiotics? </p>
<p>Through <a href="http://www.bristol.ac.uk/primaryhealthcare/researchthemes/">our research</a> we already know that patients don’t necessarily want antibiotics – but they do want to know how best to manage infection symptoms. We’ve learned that even one course of antibiotics increases the chance that a patient in primary care will subsequently have resistant bacteria. We known that many infections last longer than we think, and knowing this can help us be more realistic about what to expect. And we discovered that ibuprofen is superior to paracetamol for relieving fever in children, and both alternated are superior to either alone. </p>
<p>Together with colleagues from across the world, our collective effort to answer the big questions will help patients, doctors, nurses and the NHS achieve the goal of effective antibiotic use. In this way, patients can continue to benefit from the miracle treatment that Fleming first discovered 90 years ago. So here’s to another 70 years of the NHS – and another 90 of effective antibiotics.</p><img src="https://counter.theconversation.com/content/100684/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alastair Hay receives funding from the National Institute for Health Research (part of the NHS). He is a member of the NICE Managing Common Infections Antimicrobial Prescribing Guideline Group.</span></em></p>Alexander Fleming’s work has helped countless people over the last nine decades.Alastair Hay, Professor of Primary Care, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/996202018-08-01T13:40:36Z2018-08-01T13:40:36ZInappropriate chaperoning during intimate examinations could be endangering vulnerable patients<figure><img src="https://images.theconversation.com/files/229432/original/file-20180726-106511-1fv4h7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inside the examination room. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bed-opd-out-patient-clinic-doctor-714543706?src=2fYkf1Jvs7o3FC-rWb_uSw-1-26">Beaukeh Bottega/Shutterstock</a></span></figcaption></figure><p>Intimate health examinations can be an uncomfortable experience for anyone, regardless of age, health or gender. We are taught to trust doctors, believing they will not judge, that they are simply there to medically assess us, but still the prospect can be a daunting one.</p>
<p>There are protections in place, however. Anyone <a href="https://www.hey.nhs.uk/patient-leaflet/chaperone-advice-patientsparents/">can ask for a chaperone</a> (an impartial adult) to attend a health screening with them. Though there is no legal basis for a patient requesting a chaperone, it has become a common practice <a href="http://www.wales.nhs.uk/sitesplus/documents/863/Chaperoning%20Policy.pdf">within the NHS</a>, and accepted by bodies such as the <a href="https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/intimate-examinations-and-chaperones">General Medical Council</a>.</p>
<p>But despite overhauls in the law, there is still little concrete guidance on the exact role and responsibilities of a chaperone. And though the purpose of this person is to independently observe what is going on during a medical examination, doctors have been encouraged to use a chaperone <a href="https://www.bmj.com/content/330/7498/s175.2">to protect themselves</a> from potential accusations of inappropriate behaviour.</p>
<h2>Unclear laws</h2>
<p>Following the imprisonment of <a href="https://www.theguardian.com/society/2002/apr/29/medicineandhealth.lifeandhealth">GP Clifford Ayling</a> for sexually abusing female patients in 2004, a Department of Health inquiry found that there were actually <a href="https://books.google.co.uk/books?id=LVwCDgAAQBAJ&pg=PT125&lpg=PT125&dq=ayling+inquiry+A+chaperone+provides+a+safeguard+against+humiliation,+pain+or+distress&source=bl&ots=G9PZbam7cA&sig=0hZH2nnH-8S8v95TxJYJ_isM7Do&hl=en&sa=X&ved=2ahUKEwjU8evFvrrcAhVLSsAKHYFbDE4Q6AEwAHoECAEQAQ#v=onepage&q=ayling%20inquiry%20A%20chaperone%20provides%20a%20safeguard%20against%20humiliation%2C%20pain%20or%20distress&f=false">four definitions that could be attached</a> to the chaperone’s role, including that they are a “safeguard” for the patient, who “provides physical and emotional comfort” and will “identify unusual or unacceptable behaviour” from a healthcare professional, but also protect the professional from “potentially abusive patients”.</p>
<p>The lack of further clarity on the role and responsibilities of a chaperone is concerning. The idea of chaperoning is linked to the legal principle of <a href="http://www.oxfordreference.com/view/10.1093/oi/authority.20110803095755504">equality of arms</a>. This forms part of the right to a fair trial, where both sides in a dispute should have the same opportunities to defend themselves. It should mean that chaperones are objective in their reporting of an examination, and that they are not involved solely to safeguard the patient, nor only to provide a second voice to support a doctor’s case.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230221/original/file-20180801-136655-z7x9wg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Reassurance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-doctor-reassuring-her-female-patient-1008495334?src=qaQysWa5We24cWWRLqb4kQ-2-49">nuiza11/Shutterstock</a></span>
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<p>The <a href="https://www.bipsolutions.com/docstore/pdf/8221.pdf">inquiry did recommend</a> that robust policies be put in place, and that only trained chaperones witness medical examinations. But 16 years on, many NHS trusts and health boards still do not have standardised procedures to follow. This lack of definitive safeguarding may be putting patients at risk, with potential problems ranging from improper practices (such as patients being given inadequate psychological and emotional support during traumatic examinations, by either chaperone or doctor) up to sexual assault.</p>
<p>While chaperone rules have stagnated, several cases involving the sexually motivated abuse of patients by doctors – which could have been mitigated by the presence of chaperones – have come to light. These include <a href="https://www.theguardian.com/uk-news/2015/oct/22/clues-missed-over-childrens-doctor-who-abused-patients-myles-bradbury">paedophile doctor Myles Bradbury</a> (who ignored a <a href="https://www.bbc.co.uk/news/uk-england-cambridgeshire-34591633">hospital chaperone policy</a>), and more recently, <a href="https://www.theguardian.com/world/2018/jan/18/midlands-gp-jailed-12-years-for-sex-attacks-on-four-female-patients">GP Jaswant Rathore</a>, who “deliberately avoided offering chaperones” and was jailed after sexually abusing female patients between 2008 and 2015. </p>
<p>However, the presence of a chaperone does not always prevent inappropriate behaviour – as illustrated by the Ayling case. The inquiry was told that the availability of a chaperone did not prevent Ayling from acting unprofessionally. In fact, the chaperone was <a href="https://www.theguardian.com/society/2002/apr/29/medicineandhealth.lifeandhealth">sent out of the room</a> from time to time. </p>
<h2>Rates and research</h2>
<p>The rates of chaperone uptake are low – as is the amount of research being done on this issue. One <a href="https://www.bmj.com/content/330/7495/846.2">six-month survey of doctors</a> found that while 92% of the 252 patients seen were offered a chaperone, only 22% accepted, while 12% expressed no preference. The remaining 66% declined because they trusted the doctor, thought it unnecessary, wanted privacy, were embarrassed, or were not bothered. Fewer male patients in the study accepted chaperones than female patients (3%). But significantly more female patients accepted chaperones from male doctors (85.4%) than from female doctors. </p>
<p>Other studies have found that nearly half of male GPs <a href="https://www.bmj.com/content/330/7485/235">never or rarely use</a> chaperones when intimately examining women. While some – worryingly – use receptionists as chaperones. In fact, in 2005, researchers found that only <a href="https://www.bmj.com/content/330/7485/234">37% of GPs had a chaperoning policy</a>, with lack of staffing and resources given as excuses.</p>
<p>It is clear that more needs to be done to protect the vulnerable and prevent abuse – but what? It could be argued that there is no role for a chaperone and the installation of video cameras could provide a more effective way of preventing inappropriate behaviour, also serving to protect doctors from false allegations. But that may give rise to other privacy concerns.</p>
<p>The system is in a mess, and although policies are in place, they are not robust enough to ensure patients aren’t at risk. To begin with – and to ensure there is patient autonomy and transparency of professional practice – the role of the chaperone needs to be properly defined. They must be employed with a contract that clearly shows the parameters of the role. In addition, patients must be fully informed of the whole process for it to be lawful. Only then can we start to address and stop any sexual abuse that may occur.</p><img src="https://counter.theconversation.com/content/99620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Joseph does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients may be at risk while chaperones fail to act impartially.Paul Joseph, Director of the Centre For Life Ethics and Organ Donation and Lecturer in Health Care Law and Ethics, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.