tag:theconversation.com,2011:/nz/topics/primary-care-1206/articlesPrimary care – The Conversation2024-02-01T13:30:51Ztag:theconversation.com,2011:article/2166032024-02-01T13:30:51Z2024-02-01T13:30:51ZSuicide has reached epidemic proportions in the US − yet medical students still don’t receive adequate training to treat suicidal patients<figure><img src="https://images.theconversation.com/files/562904/original/file-20231201-17-ssns1k.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5982%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every year, more than 12 million Americans have suicidal thoughts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/tired-and-downcast-man-holding-head-with-hands-royalty-free-image/1472116942?phrase=suicide&searchscope=image%2Cfilm&adppopup=true">Djavan Rodriguez/Moment via Getty Images</a></span></figcaption></figure><p>Suicide in the U.S. is <a href="https://www.mentalhealthfirstaid.org/">a societal epidemic</a> and a <a href="https://www.kff.org/mental-health/issue-brief/a-look-at-the-latest-suicide-data-and-change-over-the-last-decade/">staggering public health crisis</a> that demands attention from medical experts.</p>
<p>In 2021, <a href="https://www.cdc.gov/suicide/suicide-data-statistics.html">someone in the U.S. died by suicide every 11 minutes</a>, according to the Centers for Disease Control and Prevention. That rate equates to nearly 50,000 Americans every year. Another 1.7 million people in the U.S. attempted suicide in 2021, and over 12 million more had suicidal thoughts. </p>
<p>And the numbers appear to be getting worse: Preliminary numbers for 2022 show a <a href="https://www.nytimes.com/2023/08/11/well/mind/suicide-deaths-2022-cdc.html">2.6% increase in suicide deaths from 2021</a>. </p>
<p>Suicide particularly affects younger people – it remains one of the top three causes of death for those between ages 10-34. High school students identifying as lesbian, gay, bisexual, transgender, queer and questioning, or LGBTQ+, attempt suicide <a href="https://www.thetrevorproject.org/resources/article/facts-about-lgbtq-youth-suicide/">four times more often than heterosexual students</a>. </p>
<p>These statistics make it clear that far more attention needs to be given to how to talk about suicide, both with loved ones and in medical and other professional settings. </p>
<p>As <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/office-of-medical-education/rbonnin.html">a team of experts</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/gralnikl.html">who educate medical students</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/ndesmara.html">on how to identify</a> and treat suicidal patients, we are well aware that most medical schools <a href="https://doi.org/10.1097/ACM.0000000000004008">do not yet adequately address the topic of suicide</a>. </p>
<p>In turn, many of their students, once they become physicians, are not adequately equipped to identify, assess and refer suicidal patients. Yet, these health care providers are expected to <a href="https://doi.org/10.3389/fmed.2022.892205">play a key role</a> in the battle to prevent suicide. But as the numbers make clear, this approach is not enough.</p>
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<figcaption><span class="caption">The signs of someone considering suicide include giving away possessions and abusing drugs or alcohol.</span></figcaption>
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<h2>Destigmatizing suicide</h2>
<p>Suicide has a long history of stigma, made worse by how it’s <a href="https://theactionalliance.org/messaging/entertainment-messaging/national-recommendations">portrayed in the media</a>. Often, when someone dies by suicide, the media uses euphemistic phrases such as “no foul play suspected,” rather than clear and accurate language describing the death as a suicide. This type of coded language implies the subject of suicide should not be addressed directly and <a href="https://link.springer.com/chapter/10.1007/978-3-030-26840-4_1">leaves questions about what actually happened</a>. </p>
<p>When a person takes their own life, the phrase <a href="https://www.dailymail.co.uk/news/article-12856353/Emily-Matson-Pennsylvania-suicide-train.html">“committed suicide” is often used</a>, as if it were a sin or a crime. This is partly because, historically, most religions have considered suicide to be sinful and as a result it is <a href="https://doi.org/10.1111/1467-9566.12224">treated as taboo</a>. Although laws against suicide have been <a href="https://ethics.journalism.wisc.edu/2023/03/10/a-guide-to-responsible-reporting-on-suicide/">repealed in the United States and many other places</a>, attempted suicide is still <a href="https://www.law.cornell.edu/wex/suicide">considered a crime in some states</a>. </p>
<p>The verb “commit” in the context of suicide can <a href="https://twitter.com/APStylebook/status/1160941325073731584">suggest a criminal act</a>. In contrast, using language such as “died from suicide” or “took her own life” is less stigmatizing and more neutral, which is why these phrases are <a href="https://www.hse.ie/eng/services/list/4/mental-health-services/nosp/resources/language-and-suicide/">recommended by advocates of mental health</a> as best practices. Consistent with this approach, many media organizations have developed specific guidelines for reporting about suicide. For example, the Associated Press Stylebook recommends <a href="https://www.apstylebook.com/ap_stylebook/suicide">avoiding use of the phrase “committed suicide</a>.” </p>
<p>Similarly – largely because of the societal and historical stigma surrounding suicide, which medical education is not immune to – medical schools do not equip up-and-coming doctors with the language and skills needed to recognize it and properly address it with their patients.</p>
<h2>Shortage of mental health care</h2>
<p>The first point of contact for patients seeking treatment for mental health conditions is usually their primary care physician. About 44% of those who died by suicide worldwide between 2000 and 2017 had visited their primary care provider <a href="https://doi.org/10.1177/1403494817746274">within one month of their death</a>. </p>
<p>This could be due to a combination of factors, including the continued stigma of mental health, <a href="https://theconversation.com/as-the-mental-health-crisis-in-children-and-teens-worsens-the-dire-shortage-of-mental-health-providers-is-preventing-young-people-from-getting-the-help-they-need-207476">limited access to mental health professionals</a> and ease of access to and comfort with their primary care practitioner as a first step. Research shows that gaps between general medical services and specialty mental health options are preventing adults and kids from <a href="https://doi.org/10.1016/j.apnu.2019.08.001">getting the mental health care</a> they need.</p>
<p>In addition, the vast majority of patients with depression are treated by their primary care physicians rather than psychiatrists. </p>
<p>The shortage of available psychiatrists means that primary care physicians provide treatment and prescribe mental health care by default, especially for children, adolescents and geriatric patients. In fact, primary care providers – in other words, practitioners who are not psychiatrists – prescribe more than half of all psychiatric medication. And a 2023 study found that approximately one-third of patients received <a href="https://doi.org/10.1007/s10488-023-01290-x">mental health care from their primary care provider</a>. </p>
<p>Finally, many psychiatrists in private practice do not accept insurance, including Medicare and Medicaid, leading to <a href="https://doi.org/10.1001%2Fjamapsychiatry.2013.2862">reduced availability of psychiatric care</a>. </p>
<p>Thousands of additional lives might be saved if primary care physicians and other practitioners who are not psychiatrists were better trained to ask the vitally important questions about suicide. In addition, better recognition of the warning signs of suicide, readily available psychiatric care and the elimination of stigma of mental illness would facilitate better quality of care. </p>
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<figcaption><span class="caption">Psychiatry and behavioral health professors Rodolfo Bonnin and Nathaly Shoua-Desmarais talk about the urgent need for suicide education for all doctors, not just psychiatrists.</span></figcaption>
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<h2>Training the next generation of doctors</h2>
<p>Why do so many Americans take their lives shortly after seeing a primary care provider? </p>
<p>It may be because many doctors are <a href="https://doi.org/10.1027/0227-5910/a000555">unprepared or uncomfortable discussing suicide</a> or don’t pick up on the signs of <a href="https://pubmed.ncbi.nlm.nih.gov/33351435/">suicidal ideation</a>. It’s also possible that the doctors simply don’t have the necessary time to spend with the patients, even when intervention is needed. </p>
<p><a href="https://medicine.fiu.edu/about/departments/psychiatry-and-behavioral-health/">At Florida International University</a>, we train all medical students, beginning in the first year, on how to discuss suicide with patients. This helps to normalize the topic as just another part of their medical training, which, in turn, destigmatizes it. </p>
<p>We then emphasize the need for comfort and familiarity with the topic, as well as the many myths surrounding it. For example, there’s a false belief that asking a patient about suicide will increase the likelihood they will act upon the suicide. <a href="https://doi.org/10.1080/13811118.2020.1793857">Research indicates otherwise</a>. </p>
<p>Finally, students are told that doctors must create a safe environment for their patients to be open about discussing sensitive topics. In short, doctors must ask questions about suicide in a way that’s not pejorative or dismissive. They must not apologize to the patient or shy away from the subject.</p>
<p>Statements like “I’m sorry to have to bring this up” or “I’m sorry if this question seems too personal” can be an indication of discomfort or uneasiness. Instead, doctors should ask direct and specific questions like “Have you had any thoughts about ending your life” or “Are you having any thoughts of suicide?” </p>
<p>After a risk assessment is completed, then a patient would be hospitalized if they are at risk – there is no mandate for doctors to report on or act on depression.</p>
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<figcaption><span class="caption">Suicidal ideation is an emergency.</span></figcaption>
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<h2>The need for universal suicide screening</h2>
<p>Although universal suicide screening has yet to be made the best practice nationally, there are multiple reasons why a standard screening process would be beneficial. Training in suicide assessment and prevention can be made mandatory for medical license renewal, which would include universal screening practices. </p>
<p>For example, <a href="https://www.pewtrusts.org/en/research-and-analysis/articles/2023/04/19/health-care-providers-laud-universal-screenings-to-help-reduce-suicide-risk">adopting best practices</a> could include offering suicide screening during routine health care visits to identify people at risk who might not otherwise be identified. </p>
<p>Another example: More than half of 15,000 children and adolescents who were seen in a pediatric hospital emergency room for nonpsychiatric reasons between March 18, 2013, and Dec. 31, 2018, were also <a href="https://doi.org/10.1176/appi.ps.202100625">experiencing suicidal ideation and behaviors</a>. These examples emphasize the critical need to train doctors in suicide assessment and prevention. Currently there are fewer than 10 states that <a href="https://www.datocms-assets.com/12810/1577013724-afsphealthprofessionaltrainingissuebrief6-7-19.pdf">require any training on suicide assessment and prevention</a> for doctors to renew their medical license.</p>
<p>In addition, doctors can use empathy, compassion and a nonjudgmental approach, rather than making the patient feel like they are being cross-examined by a lawyer. Interacting empathically leaves the patient feeling more understood and comfortable disclosing sensitive information. </p>
<p>There is a growing movement <a href="https://doi.org/10.1097/ACM.0000000000004008">toward addressing mental health issues</a> in medical schools. Our program prioritizes training a new crop of physicians who will be prepared and motivated <a href="https://doi.org/10.1007/s40596-021-01485-0">to discuss suicide with their patients</a>. </p>
<p><em>If you or someone you know is considering suicide, please <a href="https://988lifeline.org/">call or text 9-8-8 for confidential, free support</a>.</em></p><img src="https://counter.theconversation.com/content/216603/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 organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Close to half of those who die by suicide saw a primary care doctor within a month of their death.Rodolfo Bonnin, Assistant Dean for Institutional Knowledge Management and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLeonard M. Gralnik, Chief of Education and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityNathaly Shoua-Desmarais, Assistant Dean for Student Success and Well-Being and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2149372023-10-18T19:34:26Z2023-10-18T19:34:26ZThe impact of not having a family doctor: Patients are worse off, and so is the health system<figure><img src="https://images.theconversation.com/files/554202/original/file-20231017-27-bh0m9p.jpg?ixlib=rb-1.1.0&rect=1023%2C335%2C4423%2C2998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fixing the family doctor shortage can save lives and money at the same time.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-impact-of-not-having-a-family-doctor-patients-are-worse-off-and-so-is-the-health-system" width="100%" height="400"></iframe>
<p><a href="https://doi.org/10.1503/cmaj.1096049">About 6.5 million Canadians</a> — roughly one in six — do not have access to primary medical care.</p>
<p>It’s a problem that puts their health at greater risk and renders the <a href="http://dx.doi.org/10.1136/fmch-2023-002236">entire public health-care system</a> less efficient than it could be, both economically and in terms of the quality of care for everyone.</p>
<p>In other words, if we can fix the shortage of family physicians, we can save lives and money at the same time.</p>
<h2>Shortage of family physicians</h2>
<p>Many factors are contributing to our current shortage.</p>
<p>For one, Canada’s health system needs not only more family doctors, but also more nurses and other health-care professionals. However, it <a href="https://www.cma.ca/our-focus/workforce-planning">lacks the capacity to collect and analyze data that’s required for integrated and proactive health human-resource planning</a>.</p>
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<img alt="A woman with gray hair in a white coat and stethoscope listening to a person with their back to the camera" src="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=457&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=457&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=457&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=574&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=574&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=574&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">The family medicine workforce is aging: Nearly one in six family doctors in Canada is 65 or older and nearing retirement.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The increasing complexity and responsibility of family medicine, including a much greater <a href="https://www.cma.ca/news/addressing-physicians-administrative-burden-invisible-crisis-family-medicine">administrative burden</a>, has also made careers in family medicine less attractive. In 2015, 38 per cent of graduating medical students chose a career in family medicine. By 2022, <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">that number had dropped to 30 per cent</a>.</p>
<p>We are also losing practising family physicians. The rate of retirement <a href="https://www.cbc.ca/news/canada/toronto/ont-family-physicians-1.6596653">increased through the pandemic</a>. (Many doctors lost income during shutdowns but were still responsible for lease and staff costs.) The current family medicine workforce is also aging: <a href="https://www.theglobeandmail.com/canada/article-family-doctors-retiring/">Nearly one in six family doctors in Canada is 65 or older and nearing retirement</a>.</p>
<h2>Family doctors and health care</h2>
<p><a href="https://www.cfp.ca/content/69/4/269.long#ref-27">Research has shown</a> that patients who have a regular general-practitioner relationship for more than 15 years need about 30 per cent less after-hours care or hospital admissions and experience approximately 25 per cent less mortality compared to those who had a regular general practitioner for just one year.</p>
<p>Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</p>
<p>While other specializations concentrate on narrower aspects of medicine, family physicians specialize in comprehensive medicine, and engage with patients directly over time. Family doctors know how to manage a huge range of symptoms and conditions across the span of a lifetime. </p>
<p>In fact, <a href="https://doi.org/10.1016/j.hjdsi.2015.02.002">a recent study</a> in the United States rated family medicine as the most complex of all medical specialties, requiring the highest degree of judgement and integrated knowledge.</p>
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<img alt="A doctor seen from behind with a woman and a child" src="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?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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<span class="caption">Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The work, while challenging, is valuable and <a href="https://doi.org/10.1503/cmaj.180186">makes the rest of the health-care system more efficient</a>.</p>
<p>Having a person or a team get to know your story over time is incredibly powerful. When I see patients I’ve known for a long time, we can get a lot done quickly. They tell me what’s worrying them, and together we can decide quickly if a familiar issue calls simply for assurance and encouragement, or whether something has changed and needs addressing.</p>
<p>We make these decisions based on symptoms and past medical history — factoring in elements such as stress, family situations, grief and expectations for health. Because patients know and trust me, I can tell them, “I think XYZ is going on, but if you see these symptoms or changes in the next four weeks, I want to hear about it.”</p>
<p>That trust provides the opportunity to reassure and the chance to separate something benign from something worrisome, which in turn offers incredible efficiency back to the system. Family physicians aren’t sending folks for long lists of <a href="https://doi.org/10.3122/jabfm.2011.03.100170">unnecessary investigations</a>, because we know our patients’ stories.</p>
<h2>Benefits for patients and the health system</h2>
<p>There is a belief in some circles that if we only shared one <a href="https://doi.org/10.1503/cmaj.181647">common medical record</a>, every patient’s story would become available to all, resolving the issue of providing continuity.</p>
<p>But having one person or team look after a patient’s primary care and keeping a good history is not the same as having many people looking after that patient and adding to that record in many settings and situations.</p>
<p>Patients without a family doctor must try to access the health-care system by going to an ER or walk-in clinic. That often means <a href="https://www.cihi.ca/en/nacrs-emergency-department-visits-and-lengths-of-stay">a long wait</a>, only being able to address one issue at a time and possibly that the treatment they will be offered will resolve the immediate concern, but <a href="https://doi.org/10.1002/hpm.2632">won’t necessarily address the root of the issue</a>.</p>
<p>Further, those patients likely miss the chance to tell a chapter of their health story to someone who will remember if a similar issue comes up in the future.</p>
<p>Family doctors are also experts in prevention. They know how to look for things that could become problematic down the line. Lack of access to family medicine puts people at greater risk of having diseases such as cancer <a href="https://doi.org/10.1038/nrclinonc.2013.212">go much longer without being diagnosed or treated</a>. </p>
<p>Finally, as anyone with a loved one dependent on help for the essential activities of daily life can tell you, <a href="https://www.hqontario.ca/Portals/0/documents/system-performance/connecting-the-dots-report-en.pdf">co-ordinating care</a> is a critical and effective function of family medicine.</p>
<p>Whether it’s referring patients to resources or specialized help or orchestrating something as personal and impactful as the choice to die at home, family doctors are experts in translating your health story into plans to assemble and oversee your broader health-care team.</p>
<p>The return on investment in a strong primary care foundation is an <a href="https://doi.org/10.1503/cmaj.109-5729">increase in the average lifespan</a>, a greater sense of health overall and a <a href="https://doi.org/10.1111/j.1468-0009.2005.00409.x">reduction in costs</a> in all other parts of the system.</p>
<p>The lack of family physicians is a problem worth solving.</p><img src="https://counter.theconversation.com/content/214937/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cathy Risdon 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>The shortage of family doctors affects not only patients, but the entire health-care system. A strong primary care foundation increases average lifespan, improves overall health and reduces costs.Cathy Risdon, Professor and Chair, Family Medicine, McMaster, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130572023-10-01T15:12:23Z2023-10-01T15:12:23ZFamily doctor shortage: Medical education reform can help address critical gaps, starting with a specialized program<figure><img src="https://images.theconversation.com/files/551040/original/file-20230928-25-8o9ec7.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5689%2C3386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A program offers training and education specifically on family medicine from the start of medical school, while bypassing administrative hurdles to residency.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/family-doctor-shortage-medical-education-reform-can-help-address-critical-gaps-starting-with-a-specialized-program" width="100%" height="400"></iframe>
<p>Recent reports indicate that <a href="https://doi.org/10.25318/1310048401-eng">over six million Canadians are without a family doctor</a>. This not only has a massive impact for those individuals, <a href="https://doi.org/10.1136%2Ffmch-2023-002236">but also for the entire health-care system</a>. Given current caseloads, about 4,000 family doctors would be required to address the current shortfall.</p>
<p>Education reform is part of the solution to this crisis. A new family medicine program in Ontario is designed to ensure that candidates who are the most qualified and motivated to pursue a community-based family practice get appropriate and comprehensive training. </p>
<p>The <a href="https://meds.queensu.ca/academics/queens-lakeridge-health-md-family-medicine-program">Queen’s-Lakeridge Health MD Family Medicine Program</a> focuses training and education on family medicine from the start of medical school, then advancing directly to residency. We were both involved in the conception and development of the program, Anthony Sanfilippo as senior advisor for educational expansion and innovation, and Jane Philpott as dean.</p>
<h2>Current medical education</h2>
<p>Under the existing system, medical schools across <a href="https://doi.org/10.12927%2Fhcpol.2021.26429">Canada welcomed about 3,100 young people</a> in September. They are eager, academically accomplished and committed. They have succeeded (some would say survived) a gruelling and competitive process that left the other 80 per cent of their similarly accomplished and committed co-applicants disappointed.</p>
<p>Given the <a href="https://doi.org/10.1503/cmaj.109-5704">minuscule attrition rate</a> after medical school admission and availability of postgraduate training positions, they are essentially assured of a career in medicine. That career, in today’s expanded world of specialization and sub-specialization, could be in any of well over 100 distinct areas of medical practice. Some of those fields are in desperate need of new recruits, particularly family medicine. </p>
<figure class="align-center ">
<img alt="A group of people in white coats listening to a colleague" src="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.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 program is designed deliberately to prepare them for a career in community-based family medicine, and will include early clinical learning in family practice settings.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Despite these pressing needs, students enter medical school with no commitment to any particular area of practice. Given <a href="https://www.carms.ca/pdfs/carms-forum-2023.pdf">current patterns of career selection</a>, it may be as few as 700 medical graduates per year who will be taking up the <a href="https://www.cfpc.ca/CFPC/media/Resources/Research/FM-Longitudinal-Survey-T1-entry-2021-Aggregate-Report.pdf">comprehensive, continuing family practices</a> that would address the needs of those patients.</p>
<p>In fact, much of their next three or (usually) four years in medical school will involve exploring various career options and engaging in yet <a href="https://doi.org/10.1503%2Fcmaj.170791">another highly competitive and arduous process</a> at the end of medical school to obtain a postgraduate training position. </p>
<p>In order to accomplish all this, their curricula will provide, in addition to scientific and professional skills common to all physicians, a broad sampling of specialties. This sampling will include learning, performance and clinical engagement in many areas of practice that they will never actually undertake or, if they do, will need to relearn and refine in their postgraduate training program.</p>
<p>What’s clear is that, without significant reform, modest expansion and even opening new schools will not come close to addressing our needs within the current training paradigm. </p>
<h2>A program specific to family medicine</h2>
<p>This year, for the first time, things will be different for the 20 students entering the new Queen’s-Lakeridge Health MD Family Medicine Program. Their admission was based not only on exemplary academic and personal credentials, but also on their commitment to a career in family medicine.</p>
<p>The program they are about to undertake is designed deliberately to prepare them for those careers, will include early clinical learning in family practice settings and will be taught predominantly by family physicians who are in active clinical practice providing the comprehensive, continuing, community-based care so desperately needed in our country.</p>
<figure class="align-center ">
<img alt="A doctor in an examining room with a woman and child" src="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.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">
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<span class="caption">The program will be taught predominantly by physicians who are in active clinical practice as family physicians providing comprehensive, continuing, community-based care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>It began as a partnership between <a href="https://meds.queensu.ca/">Queen’s University School of Medicine</a> and <a href="https://www.lakeridgehealth.on.ca/">Lakeridge Health</a>, an integrated organization of five hospitals and over 20 community health locations providing care to the residents of Durham region. It was based on a shared recognition that medical schools have a role in addressing the critical shortage of family physicians impacting so many Canadians, and that this shortage can, in part, be addressed by providing specialized admission opportunities and more purpose-driven education to motivated applicants. </p>
<p>It also seeks to develop models of medical education that address the real needs of contemporary society, evolving in response to the expansion and diversification of medical practice. Medical problems that were previously treated exclusively in hospital or required only palliative management are now very effectively managed chronically with medication and regular followup in the community.</p>
<p>Durham Region provides an ideal location for this program given its increasing and highly diversified population. It’s also home to multiple, well developed medical practice settings (including acute care hospitals, chronic care and mental health facilities, ambulatory clinics, and both group and individual practices) as well as committed medical and administrative communities who have longstanding associations with Queen’s. </p>
<figure class="align-center ">
<img alt="A group of health professionals, some wearing scrubs and white coats" src="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&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">Family doctors often practise in primary care teams along with multidisciplinary health-care workers such as nurse practitioners, dietitians and social workers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Queen’s School of Medicine and Lakeridge Health jointly proposed, and were supported by the Ontario Ministry of Health, in the development of this continuous six-year program that would prepare students to become qualified family physicians focused on providing comprehensive, continuing, community-based care.</p>
<h2>Themes specific to family medicine</h2>
<p>A joint Queen’s-Lakeridge Health Working Group was established to explore and implement the program based on four key themes:</p>
<p><strong>Admissions</strong> – After identifying attributes appropriate to a successful career in family practice, a novel admission process was developed that assesses academic aptitude for medicine as well as personal qualities and commitment that will promote both practice satisfaction and retention within communities.</p>
<p><strong>Curriculum</strong> – A novel curriculum was developed focused on fundamental and clinical training relevant to family medicine, with early and continuing placements in community practice settings. The curriculum incorporates key components of the undergraduate MD program and postgraduate family medicine program into an integrated program without the necessity for a secondary application process. The concept is that students will learn how to provide care to patients of all ages, in the types of settings in which they will eventually practise.</p>
<p><strong>Faculty Engagement</strong> – The faculty team blends Queen’s instructors based in Kingston with newly recruited faculty members in the Durham Region medical community. New faculty are welcomed into the Queen’s teaching community with an orientation and instruction process. Students will be learning from doctors who are actively involved in the type of practice in which they are training.</p>
<p><strong>Community Engagement</strong> – The new program is located in Durham Region. Together with Lakeridge Health administration and medical staff, facilities for teaching, housing and community placements have been established. In addition, student support and counselling have been developed locally, with strong support and integration with Kingston-based services.</p>
<h2>Addressing a critical gap</h2>
<p>These students will be able to undertake studies and training that will prepare them for their intended career, in the sort of settings in which they will eventually practise, and with guidance and mentorship of practising faculty. Their learning will be focused on family medicine. They will not be required to undertake any secondary application process, and will have considerable flexibility to tailor their training to the requirements of their eventual practice destination. </p>
<p>The aim is for them to emerge from the program prepared to qualify and practise as family physicians. </p>
<p>Importantly, this approach, although designed at this point for family medicine, could serve as a model for other medical specialties to address current and future medical workforce requirements.</p><img src="https://counter.theconversation.com/content/213057/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>Education has a role to play in addressing the shortage of family doctors. A new program is designed specifically for comprehensive, community-based family practice.Anthony Sanfilippo, Professor of Medicine (Cardiology), Queen's University, OntarioJane Philpott, Dean, Queen's Health Sciences, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2128672023-09-26T21:10:43Z2023-09-26T21:10:43ZAre seniors being pressured into retirement homes by lack of community services?<figure><img src="https://images.theconversation.com/files/549798/original/file-20230922-29-uw9xz2.jpg?ixlib=rb-1.1.0&rect=715%2C169%2C7881%2C5254&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Retirement homes might seem like less of a lifestyle choice and more like relocation imposed upon older adults by fragmented and under-resourced primary and community care services.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/are-seniors-being-pressured-into-retirement-homes-by-lack-of-community-services" width="100%" height="400"></iframe>
<p>Ads for retirement homes often feature an older couple relaxing in comfortable surroundings, playing a board game or enjoying a meal with friends. They look well — and young for their age — with broad smiles and perfect silver hair. </p>
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<a href="https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Collage of three photo of healthy, smiling older adults." src="https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=488&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=488&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=488&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=613&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=613&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550125/original/file-20230925-26-eb6i3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=613&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">Ads for retirement homes seem to offer a worry-free lifestyle choice. Above: stock images seen in marketing materials for retirement homes in Canada.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>These ads offer worry-free, active retirement living at its fullest, complete with delicious and nutritious food. It looks like a wonderful lifestyle choice. </p>
<p>But is it really a lifestyle choice? Or, is it imposed upon older adults by fragmented and under-resourced primary and community care services?</p>
<h2>Assisted living</h2>
<p>In Canada, retirement homes (also known by other names like assisted living) are increasingly for-profit living facilities for older adults. They offer a variable range of services paid for by residents. Across Canada, <a href="https://www.comfortlife.ca/retirement-community-resources/retirement-cost">monthly fees range from $1,600 to over $6,000 for spaces ranging from 300 to 600 square feet</a>. </p>
<p>In Ontario, <a href="https://www.cmhc-schl.gc.ca/blog/2021/2021-seniors-housing-survey-learn-more-insights">where monthly fees for retirement homes average almost $4,000</a>, at least two services must be provided, such as meals and medication administration, with additional services often available at extra cost. </p>
<figure class="align-center ">
<img alt="Two older women sitting at a table while a young man wearing an ID badge talks to them" src="https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549801/original/file-20230922-24-ripe1o.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">In Ontario, retirement homes must provide at least two services, such as meals and medication administration.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Some homes (for extra fees) offer services geared towards people with cognitive impairment, and others provide nursing and personal care to those who require physical support. Yet, these privately paid services are often not enough. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344365/">A 2017 study</a> in the Hamilton Niagara Haldimand Brant region of Ontario showed that up to 40 per cent of retirement home residents receive publicly funded home care services, in addition to those purchased from the home. In almost one-third of these cases, retirement home residents or their caregivers said they would be better off living elsewhere, such as in long-term care (LTC) homes, where they can receive 24-hour access to nursing and personal support services. </p>
<p>In Ontario, <a href="https://www.closingthegap.ca/long-term-care-homes-vs-retirement-homes-vs-home-care-in-ontario/">retirement homes are almost exclusively private facilities</a> offering accommodations and some paid care services for less frail seniors, and they operate under less stringent regulations by the <a href="https://www.ontario.ca/page/ministry-seniors-accessibility">Ministry for Seniors and Accessibility</a>. </p>
<p>In contrast, LTC homes provide 24/7 nursing care for more dependent individuals and are regulated and subsidized by the <a href="https://www.ontario.ca/page/ministry-long-term-care">Ministry of Long-Term Care</a>. Retirement homes typically feature private suites or apartments, whereas LTC homes have more institutional and less private accommodations.</p>
<p><a href="https://doi.org/10.1017/S0714980820000045">A recent review of research</a> showed that the opportunity for greater social interaction in retirement homes is an important consideration for some, and consistent anecdotal reports suggest that many residents have a boost in health and well-being after moving into a retirement home. </p>
<p>However, the primary drivers of relocation are concerns over age-associated decline in health, coupled with uncertainty over being able to access services — such as assistance with property upkeep, medications or personal care — in their current home.</p>
<h2>Unmet health-care needs</h2>
<p>We still have a limited picture about <a href="https://doi.org/10.1017/s0714980813000159">what happens when someone moves into a retirement home</a>. In contrast to the LTC sector, for which we have relatively rich information sources at the national level, there is almost no information on retirement home residents. </p>
<figure class="align-center ">
<img alt="A woman in a white coat with a stethoscope and clipboard stands and talks to an older woman in a chair" src="https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549799/original/file-20230922-17-vel5bj.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 role of primary care medical providers is not regulated in retirement homes in Ontario.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>What we do know paints a mixed picture. For example, retirement home residents living with dementia, and who can afford specialized memory care services, <a href="https://doi.org/10.1016/j.jamda.2021.07.002">are less likely to move to a LTC home</a>. In contrast, retirement home residents <a href="https://doi.org/10.1503/cmaj.211883">receive far fewer primary care visits</a> than those in LTC homes, and are more likely to visit the <a href="https://doi.org/10.1016/j.jamda.2023.06.024">emergency department</a>, <a href="https://doi.org/10.1016/j.jamda.2015.01.079">be hospitalized</a> and experience prolonged hospital stays.</p>
<p>Clearly, the service and health-care needs of retirement home residents are not being met, nor were these being met in the community, compelling the move to a retirement home in the first place. </p>
<p>In Canada, under-resourcing of home- and community-care sectors imposes limits on where an older person can reside as their health declines, though more choices are available to those living in larger cities and able to pay for expensive private home care. Canada spends <a href="https://www.oecd.org/health/long-term-care.htm">substantially less per capita on home and community-care than the OECD average</a>. </p>
<p>Despite evidence that the medical needs of retirement home residents have been growing more complex, the role of primary care medical providers is <a href="https://doi.org/10.1016/j.jamda.2021.12.012">not regulated</a>, nor is there much incentive to practice in these settings. Retirement homes look like <a href="https://doi.org/10.1503/cmaj.211883">primary care deserts</a>, with residents often having no meaningful access to their previous primary care provider due to mobility limitations in transportation to off-site clinic locations. </p>
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<strong>
Read more:
<a href="https://theconversation.com/preventing-delirium-protects-seniors-in-hospital-but-could-also-ease-overcrowding-and-emergency-room-backlogs-189220">Preventing delirium protects seniors in hospital, but could also ease overcrowding and emergency room backlogs</a>
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<p>Retirement home residents are more likely to be hospitalized and experience accelerated functional and cognitive decline without access to co-ordinated, senior-friendly primary care. Reliance on the limited access to community-based primary care clinics is inadequate because outside primary care providers often can’t know the environment or staff in the retirement home. </p>
<p>Common issues, like falls, can go unaddressed given that there is no one on site to do a sufficiently thorough medical falls risk assessment. Dehydration related delirium (confusion) that could be addressed on site can instead lead to hospital admission and premature institutional care. </p>
<h2>Designed for institutionalization</h2>
<p>Our health-care system <a href="http://nationalseniorsstrategy.ca/wp-content/uploads/2020/09/NSS_2020_Third_Edition.pdf">seems designed to foster premature institutionalization</a>. The retirement home sector attempts to fill a care and service gap in the community, but is progressively less able to do so as resident care needs become more complex and exceed what they can afford out of pocket.</p>
<figure class="align-center ">
<img alt="A nurse taking a man's blood pressure on a sofa" src="https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549800/original/file-20230922-21-pyv5pf.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">
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<span class="caption">The solution requires that publicly funded and integrated home and community services be made more accessible to older people regardless of where they choose to live.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The solution requires that publicly funded and integrated home and community services be <a href="http://nationalseniorsstrategy.ca/wp-content/uploads/2020/09/NSS_2020_Third_Edition.pdf">made accessible to older people regardless of where they chose to live</a>, whether in a retirement home or in the private residence where they have lived for years. </p>
<p>Specific attention is required for community dwelling older people with cognitive difficulties, many of whom could continue aging in place with minimal assistance for nutrition, medication management and surveillance of chronic medical conditions. </p>
<p>Interprofessional primary care (teams that include multiple health professionals such as doctors, nurse practitioners, dietitians and social workers) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10198684/">would have greater capacity to support older people with complex health issues</a>. Such teams must be made available to prevent hospitalization and its often disabling consequences. </p>
<p>Since many residents have limited capacity to travel to office visits, providing on-site access to primary care in retirement homes is simply fulfilling the promise of the Canada Health Act that reasonable access to insured health services is provided to all Canadians. </p>
<p>More home care and better access to robust primary care services will better meet the needs of older adults in the community, optimize their health and independence, and reduce the huge <a href="https://doi.org/10.1503/cmaj.230719">strain on our hospitals</a> and caregivers. They will also allow older people greater choice over — and ability to afford — whatever lifestyle they prefer.</p><img src="https://counter.theconversation.com/content/212867/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>George A Heckman receives funding from the Schlegel Research Chair in Geriatric Medicine. The Schlegel Chair endowment was a charitable donation to the University of Waterloo, and there is no personal obligation to the donor. </span></em></p><p class="fine-print"><em><span>Andrew Costa receives funding from the Canadian Institutes of Health Research and the Public Health Agency of Canada for related research. He is the Schlegel Chair in Clinical Epidemiology & Aging and Canada Research Chair in Integrated Care for Seniors at McMaster University. The Schlegel Chair endowment was a charitable donation to McMaster, and there is no personal obligation to the donor. He is Research Director of St. Joseph’s Health System's Centre for Integrated Care (Hamilton).</span></em></p>Publicly funded primary and home care should be accessible to all older adults, regardless of where they live.George A Heckman, Schlegel Research Chair in Geriatric Medicine, Associate Professor, University of WaterlooAndrew Costa, Associate Professor | Schlegel Chair in Clinical Epidemiology & Aging | Canada Research Chair in Integrated Care for Seniors, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2126202023-09-06T20:13:15Z2023-09-06T20:13:15ZIt can be tough getting a GP appointment. Nurse practitioners could take some of the load<figure><img src="https://images.theconversation.com/files/546330/original/file-20230905-29-jl68t8.jpg?ixlib=rb-1.1.0&rect=0%2C131%2C5142%2C3291&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/KdWfhEwjcIE">Unsplash/Cezar Sampaio</a></span></figcaption></figure><p>Australians are living longer than ever. But these extra years of life come with higher rates of <a href="https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity">long-term and complex conditions</a> and greater health care needs. </p>
<p>The government wants to <a href="https://www.health.gov.au/sites/default/files/documents/2022/03/australia-s-primary-health-care-10-year-plan-2022-2032-future-focused-primary-health-care-australia-s-primary-health-care-10-year-plan-2022-2032.pdf">improve</a> Australians’ access to primary care services. These services would usually be delivered by a GP. But as part of this change, a new <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/unleashing-the-potential-for-our-health-workforce-review-appointment">review</a> is exploring how other health professionals could expand their current scope of work to meet growing needs. </p>
<p>Nurses make up <a href="https://www.aihw.gov.au/reports/workforce/health-workforce">more than 50%</a> of the health workforce and have untapped and under-used skills that would ease the skills gap in our health system. Within this group, <a href="https://www.acnp.org.au/aboutnursepractitioners">nurse practitioners</a> have advanced training and the potential to deliver more services than they’re currently allowed – without the oversight of a GP. </p>
<h2>How will access to primary care change?</h2>
<p>One of the big changes is that from October 2023, some patients will be able to register with one GP or general practice under the <a href="https://www.health.gov.au/our-work/mymedicare">MyMedicare</a> scheme. Those who are registered will start to have access to extra funded services like longer telehealth <a href="https://www.health.gov.au/our-work/mymedicare">appointments</a>. </p>
<p>The first patients who will get access to these benefits are people with multiple health conditions and/or additional social needs. Having one doctor who knows them, and their history, can connect them more seamlessly with all of the different health professionals and services. This saves <a href="https://pubmed.ncbi.nlm.nih.gov/31698168/">patients and carers</a> time, money and effort.</p>
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Read more:
<a href="https://theconversation.com/should-you-register-with-a-gp-what-is-mymedicare-and-how-might-it-change-the-care-you-get-206183">Should you register with a GP? What is MyMedicare and how might it change the care you get?</a>
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<p>For MyMedicare to work, Australia will need more health professionals with the right skills available in cities, regional towns and in rural and remote locations. </p>
<p>Currently, Australia is set to have a shortfall of 10,600 GPs by <a href="https://www.ama.com.au/articles/general-practitioner-workforce-why-neglect-must-end">2032</a>. This represents a serious problem. While steps are being taken to grow the GP <a href="https://insightplus.mja.com.au/2021/17/its-more-than-the-money-getting-gps-to-go-rural/">workforce</a>, this takes time. And with a <a href="https://www.who.int/news/item/02-06-2022-global-strategy-on-human-resources-for-health--workforce-2030">worldwide</a> health workforce shortage, it will not be easy. </p>
<p>Australia will need to find other solutions. One option is to look to nurses to take on tasks for which they are suitably skilled but have historically been undertaken by doctors. </p>
<h2>How nurses can help</h2>
<p>In the United Kingdom, the United States, The Netherlands and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020757/">Canada</a>, advanced nursing – where nurses have postgraduate education and training to take on more specialised tasks and roles – has been relied on for years. </p>
<p>At the most advanced level of nursing, a nurse practitioner is a trained registered nurse who provides advanced nursing care either independently and autonomously, or with a doctor. Nurse practitioners can assess and diagnose health problems, order and interpret diagnostic tests, prescribe medicines, <a href="https://www.acnp.org.au/np-fact-sheets">refer</a> patients to other health professionals and even admit them to hospitals. </p>
<p>Nurse practitioners have been practising in Australia since 2000, starting in emergency care, with <a href="https://hwd.health.gov.au/resources/publications/factsheet-nrpr-2019.pdf">more than 1,400</a> practising in total in Australia by 2019. However, unlike other countries, Australian nurse practitioners must work in collaboration with a doctor. If they were to practise more independently, nurse practitioners could expand health-care access for thousands of Australians, including those living in rural and remote areas. </p>
<p>A recent NSW Health report presented a framework for specialised rural nurse practitioners that shows how care might be provided to focus on local community <a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2022_057.pdf">needs</a>. For people living with a disability, or chronic and complex conditions, nurse practitioners can provide services in their communities, such as diagnosis, treatment plans, dialysis and make referrals to a specialist, including via telehealth. This could reduce the need for long-distance travel or a long wait time to access a GP. </p>
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<h2>Don’t we have a shortage of nurses?</h2>
<p>It is true, nurses are leaving the workforce in the thousands. One fifth of nurses in Australia intend to leave nursing in the next <a href="https://www.mckinsey.com/industries/healthcare/our-insights/should-i-stay-or-should-i-go-australias-nurse-retention-dilemma">12 months</a>. Keeping them requires better working <a href="https://researchers.mq.edu.au/en/publications/workplace-stress-and-resilience-in-the-australian-nursing-workfor">conditions</a>.</p>
<p>But it’s not just about reducing burnout, stress and workloads. Nurses want career development, the opportunity to extend their scope of practice with advanced training, and for these complex care skills to be recognised and <a href="https://www.acn.edu.au/wp-content/uploads/white-paper-optimising-advanced-practice-nursing.pdf">used</a>. </p>
<p>Access to opportunities for career development and progression is a key driver of nurse <a href="https://www.nswnma.asn.au/wp-content/uploads/2023/02/Impacts-of-COVID-19-and-workloads-on-NSW-nurses-and-midwives-mental-health-and-wellbeing_final.pdf">retention</a>. </p>
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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>Why haven’t nurse practitioners already solved the workforce crisis?</h2>
<p>Nurse practitioners are registered nurses who have additional postgraduate education and clinical training in their speciality area. </p>
<p>Nurse practitioners are currently required to work in collaboration with a doctor to deliver care, which limits the extent to which they can resolve the workforce gaps we face. A nurse practitioner can prescribe medications, for example, but must do so with oversight via a sign-off from a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/midwives-nurse-pract-qanda-nursepract#4">doctor</a>. </p>
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<img alt="Male nurse takes a woman's blood pressure" src="https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=903&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=903&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=903&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1135&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1135&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1135&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">Nurse practitioners in Australia currently need a doctors’ oversight to prescribe medications.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/7uSvaBY69d0">Unsplash/CDC</a></span>
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<p>The federal government’s <a href="https://www.health.gov.au/sites/default/files/2023-05/nurse-practitioner-workforce-plan.pdf">nurse practitioner workforce plan</a> aims to remove barriers to patients accessing a nurse practitioner. The plan is looking at whether nurse practitioners should provide Medicare-funded services, create additional nurse-led care items and remove the requirement for them to collaborate with doctors in delivering care.</p>
<p>The federal government’s current proposals may therefore see nurse practitioners working completely independently, in a similar way to that overseas.</p>
<p>But despite evidence showing nurse practitioners <a href="https://www.sciencedirect.com/science/article/pii/S1555415513004108?casa_token=7ye49Vc_XLMAAAAA:hw76-d1CjqvF-jBZ-7D_y9_DOAJzeMhav979UgBq1WOxnCdI7QfKoYPcLXxj98bZ2wjHqQQ7qw">provide safe health care</a>, the proposal has been met with <a href="https://www.racgp.org.au/FSDEDEV/media/documents/RACGP/Reports%20and%20submissions/2019/RACGP-submission-MBS-Review-Nurse-Practitioners-Reference-Group.pdf">concern</a> from some doctors that increased independence may risk patient safety and lead to more fragmented care. They also argue it would be unfair for patients who can’t see a doctor and who must see a nurse practitioner instead. </p>
<h2>What should happen next?</h2>
<p>Delivering better quality primary health care in Australia ultimately means we need to make better use of our health services and align it with our changing population needs. </p>
<p>To achieve this, we will need to grow our nurse practitioner workforce and use them more effectively. Enabling nurse practitioners to use all their skills independently might also help to stem the loss of nursing workforce.</p>
<p>But expanding the scope of any profession must be done in a way that improves collaboration, team-based working and patient-centred care. Health care is safest and most effective when health professionals work together – and with patients – to make decisions about care. So it’s important for the plan to include incentives that make collaboration more likely between nurse practitioners and doctors.</p>
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Read more:
<a href="https://theconversation.com/pharmacists-should-be-able-to-work-with-gps-to-prescribe-medicines-for-long-term-conditions-212359">Pharmacists should be able to work with GPs to prescribe medicines for long-term conditions</a>
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<img src="https://counter.theconversation.com/content/212620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Reema Harrison receives funding from National Health and Medical Research Council, Medical Research Futures Fund, Cancer Institute NSW, Australian Research Council, Medibank Better Health Fund, and NSW Health. </span></em></p><p class="fine-print"><em><span>Laurel Mimmo works for a NSW Health organisation and is a member of the NSW Nurses and Midwives Association, the Health Services Union and the Australian College of Nursing. She does not currently receive funding from any organisation. </span></em></p>Nurses make up more than 50% of the health workforce and have untapped and under-used skills that could ease the skills gap in our health system.Reema Harrison, Associate Professor, Macquarie UniversityLaurel Mimmo, Honorary Post-doctoral Fellow, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2123592023-08-29T20:13:06Z2023-08-29T20:13:06ZPharmacists should be able to work with GPs to prescribe medicines for long-term conditions<p>A national <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/unleashing-the-potential-for-our-health-workforce-review-appointment">review</a> of primary care workforce regulations is investigating ways to increase Australians’ access to quality health care.</p>
<p>The review is considering how health-care workers can use more of their skills and training, to work to their full scope of practice. This includes exploring who should be allowed to prescribe medications. </p>
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<p>Independent pharmacist prescribing is increasing around the world, and now trials are starting in most Australian states. </p>
<p>The review should focus on expanding pharmacists prescribing for stable conditions and long-term medications, under the direction of a GP.</p>
<h2>What’s the problem?</h2>
<p>It often seems like health workers are at odds, but there’s one thing the professional bodies for <a href="https://www.racp.edu.au/news-and-events/media-releases/racp-welcomes-report-from-medicare-taskforce-and-the-focus-on-multidisciplinary-care-but-patients-need-more-access-to-specialist-care">doctors</a>, <a href="https://www.apna.asn.au/about/media/budget-lays-the-groundwork-for-structural-change-in-health-care">nurses</a>, and <a href="https://ahpa.com.au/news-events/media-release-multidisciplinary-teams-the-key-to-unlocking-access-to-primary-care/">allied health workers</a> all seem to agree on: we need more team-based care. Governments agree too.</p>
<p>As rates of complex chronic disease rise, it’s no longer possible for one clinician to provide all the care, advice and support many patients need. </p>
<p>There is good <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">evidence</a> that a team of different kinds of health professionals working together can improve access to and quality of care, and reduce costs. </p>
<p>But Australia lags other countries when it comes to letting primary care professionals use all their skills. Partly as a result, Australia ranks behind most wealthy nations in the <a href="https://pubmed.ncbi.nlm.nih.gov/36134523/">share</a> of GPs who say they delegate aspects of care to other workers. </p>
<p>That’s one reason for rushed appointments and long wait times, with nearly <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">one-quarter</a> of Australians saying they wait too long to see a GP, and almost one-third not getting to see their preferred GP. </p>
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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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<p>There are lots of things holding teamwork back. They include workforce shortages in some parts of Australia, cultural barriers, inadequate IT systems, a fee-for-service funding model, and clinics getting too little support to change how they work. </p>
<p>But the rules about who can do what, and who gets paid for doing what, are a big part of the problem. That will be the focus of this review. </p>
<h2>Scope to share prescribing</h2>
<p>The Pharmaceutical Benefits Scheme funds <a href="https://www.pbs.gov.au/info/statistics/expenditure-prescriptions/pbs-expenditure-and-prescriptions">215 million</a> prescriptions each year. In the five years to 2021–22, that number rose by an average of 3.3 million prescriptions each year. </p>
<p>Those prescriptions can be written by authorised practitioners, such as doctors, dentists and optometrists, as well as nurse practitioners and midwife practitioners, who have post-graduate degrees. </p>
<p>Trials are underway to share this growing workload with pharmacists. This recognises pharmacists’ expertise in medicines, and their availability on a walk-in basis in most communities around Australia, including those with long waits for GP care. </p>
<p>It also reflects support from <a href="https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.13624">pharmacists</a> and <a href="https://chf.org.au/sites/default/files/what_australias_health_panel_said_about_pharmacy_prescription_.pdf">patients</a> for a prescribing role. </p>
<p>Victoria’s 12-month <a href="https://www.health.vic.gov.au/primary-care/victorian-community-pharmacist-statewide-pilot">pilot</a> is set to begin in October, and will allow pharmacists to prescribe repeat scripts for oral contraceptive pills, as well as treatments for some mild skin conditions and urinary tract infections (UTIs). </p>
<p>A similar <a href="https://www.nsw.gov.au/media-releases/statewide-pharmacy-prescribing-trial-to-begin">trial</a> is under way in New South Wales. </p>
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Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
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<p>Queensland, which already allows pharmacists to prescribe medications for UTIs, will begin a new <a href="https://statements.qld.gov.au/statements/96318">trial</a> later this year, allowing pharmacists to prescribe for a broader range of common health conditions. </p>
<p>Just a few weeks ago, Western Australia <a href="https://www.wa.gov.au/government/media-statements/Cook-Labor-Government/Pharmacy-option-for-UTI-diagnosis-for-Western-Australian-women-20230804">introduced</a> pharmacy prescribing for UTIs.</p>
<p>It’s new here, but in many other countries pharmacist prescribing is well established. Models vary, but pharmacists can write prescriptions in countries including Canada, New Zealand, the United States and the United Kingdom. </p>
<p>In a growing number of countries, pharmacists can prescribe independently. For example, in England <a href="https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-integration-fund/independent-prescribing/">all</a> newly qualified pharmacists will soon be able to do so. </p>
<p>An approach that has been around for longer overseas but that isn’t part of trials here, is pharmacists prescribing under a clinical management plan agreed with a patient’s GP.</p>
<p>Under this model, people with stable, long-term conditions that are being successfully managed with medication can get prescriptions renewed by their pharmacist, rather than having to return to the GP. </p>
<p>The evidence shows this type of prescribing can be just as <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011227.pub2/epdf/full">effective</a> as prescribing by doctors. </p>
<h2>What approach should Australia take?</h2>
<p>The Australian review is an opportunity to follow the evidence and catch up with other countries. If expanding prescribing rights is done carefully, it will improve access to care and reduce costs, without compromising the quality and safety of care. </p>
<p>But if there are too many prescribers working independently, it could increase fragmentation of care in a system that is already disjointed and hard to navigate. This has been one <a href="https://www.racgp.org.au/gp-news/media-releases/2023-media-releases/march-2023/it-just-gets-worse-and-worse-more-concerning-detai">criticism</a> of recent Australian pharmacy prescribing trials, all of which have some component of independent prescribing. </p>
<p>By working in partnership with GPs, pharmacist prescribing could go beyond the narrow range of medicines and conditions covered in independent prescribing schemes. It would complement <a href="https://grattan.edu.au/wp-content/uploads/2018/05/208-2016-09-23-grattan-institute-submission.pdf">effective</a> pharmacy services that review medications and advise patients about them.</p>
<p>That’s why the review should focus on collaborative prescribing for stable, chronic conditions. This will help more patients, while keeping GPs at the heart of the primary care team, making sure that the pieces fit together. </p>
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Read more:
<a href="https://theconversation.com/the-evidence-shows-pharmacist-prescribing-is-nothing-to-fear-127497">The evidence shows pharmacist prescribing is nothing to fear</a>
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<p>As in other countries, additional training will be needed for pharmacist prescribers, and a range of implementation <a href="https://academic.oup.com/ijpp/article/27/6/479/6099842">issues</a> need to be considered. This includes ensuring:</p>
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<li>pharmacists have sufficient training and skills</li>
<li>efficient systems are in place for sharing clinical information and working with GPs</li>
<li>both the pharmacists and the GPs they work with are paid appropriately. </li>
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<p>Getting to the future of team-based care that all the major health professional groups espouse will require compromise. Pharmacy prescribing is already here, and it’s likely to go further. To get the best results for patients, community pharmacists should welcome leadership from GPs, while GPs should support pharmacist prescribing.</p><img src="https://counter.theconversation.com/content/212359/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>Aaron Yin is currently on secondment to the Grattan Institute from the Victorian Department of Health.
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>A new review of Australian health care workers’ scope of practice should focus on expanding pharmacists prescribing for stable conditions and long-term medications, under the direction of a GP.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteAaron Yin, Associate, Health & Aged Care Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2061832023-07-17T20:02:39Z2023-07-17T20:02:39ZShould you register with a GP? What is MyMedicare and how might it change the care you get?<figure><img src="https://images.theconversation.com/files/533371/original/file-20230622-8583-mxjvpt.jpg?ixlib=rb-1.1.0&rect=7%2C22%2C4977%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/british-gp-examining-young-child-mother-98508353">Shutterstock</a></span></figcaption></figure><p><a href="https://www.health.gov.au/our-work/mymedicare">MyMedicare</a> is a new voluntary scheme that allows patients to register with their usual GP, in an attempt to improve continuity of care and health outcomes.</p>
<p>From October 1, the scheme will give registered patients access to longer telehealth consultations. Then, from next year, GP clinics with patients who are frequently admitted to hospital or are aged care residents will be able to access additional “blended” funding, which sits outside Medicare’s usual fee-for-service. </p>
<p>MyMedicare was announced in the May budget, with A$19.7 million of funding over four years, alongside a range of <a href="https://www.health.gov.au/sites/default/files/2023-05/building-a-stronger-medicare-budget-2023-24_0.pdf">other health reforms</a>, including funding for practice nurses to improve team-based care, as well as new incentives to increase bulk billing rates. </p>
<p>We’re still waiting on a lot of detail about how the scheme will function. But here’s what we know so far – and what it might mean for patients and GPs. </p>
<h2>What do we know about MyMedicare?</h2>
<p>The scheme is voluntary for GPs and patients. In addition to patients opting in, GPs will also need to sign up, and have been able to do so since the start of July. There will be a gradual roll out and it will take three years to cover all of Australia. </p>
<p>Though details are yet to be confirmed, from mid-2024 individual GPs will receive “<a href="https://www.acponline.org/about-acp/about-internal-medicine/career-paths/residency-career-counseling/resident-career-counseling-guidance-and-tips/understanding-capitation">capitation</a>” payments for patients who have more than ten hospital admissions per year. These patients are likely to have complex needs and multiple conditions and, for various reasons, may not be able to access a GP as much as they should. </p>
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Read more:
<a href="https://theconversation.com/health-budget-has-big-changes-reviving-our-worn-out-medicare-fee-for-service-system-and-boosting-bulk-billing-204527">Health budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing</a>
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<p>Though not yet confirmed, GPs are likely to <a href="https://www.ausdoc.com.au/news/the-mymedicare-enrolment-scheme-is-open-for-gp-practices-should-you-sign-up-now/">receive</a> $2,000 per patient per year, plus a $500 bonus for keeping patients out of hospital. The funding provides incentives for the GP to coordinate their care and provide the patient with access to nursing and allied health if required. It’s hoped this will stop patients going to hospital as often.</p>
<p>There will also be similar payments for providing regular visits to patients in residential aged care facilities. </p>
<h2>Will MyMedicare make a difference to patients?</h2>
<p>Let’s consider four key areas patients are concerned about: </p>
<p><strong>1) Continuity of care</strong></p>
<p>Research shows greater <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2753.2009.01235.x">continuity of care</a> – developing a relationship with and seeing the same provider or team for your care – improves patient outcomes and reduces costs to the health system. People who use MyMedicare to get a regular GP may see some of these benefits.</p>
<p>But many patients already see the same GP or visit the same practice, especially those with chronic conditions. So registration with a practice may not make much difference for this group of patients. What are the other benefits of registration? </p>
<p><strong>2) Reducing hospital admissions</strong></p>
<p>Avoiding hospitals can be beneficial – in hospitals, there are no home comforts, they are inconvenient for you and relatives, there is little privacy, and they can be costly. Patients with ten or more hospital admissions in a year have been targeted as they have more complex chronic conditions and may be from vulnerable populations. </p>
<p>Better access to a GP could prevent patients visiting the emergency department or prevent overnight hospital admissions. Research shows financial incentives for GPs to better manage chronic disease <a href="https://journals.sagepub.com/doi/full/10.1177/01410768211005109">can reduce hospital admissions</a>. </p>
<p>However, <a href="https://bmjopen.bmj.com/content/5/4/e007342?cpetoc=&int_source=trendmd&int_medium=trendmd&int_campaign=trendmd">hospital admissions could also increase</a> if the scheme identifies significant levels of previous unmet need.</p>
<p><strong>3) Reducing barriers to care</strong></p>
<p>MyMedicare does not directly address many of the <a href="https://link.springer.com/article/10.1186/1475-9276-12-18">barriers to accessing GP services</a>. If GPs are getting paid more and still getting fee for service payments, will MyMedicare patients be guaranteed to be bulk billed? This has not yet been mentioned, but could be an important part of the scheme to attract patients. </p>
<p>People with chronic disease have <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments/">two to three times higher</a> out-of-pocket costs than those who do not, and <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">30%</a> of patients with chronic disease would find it difficult to pay for care if they became seriously ill. </p>
<p>Unfortunately MyMedicare will not directly reduce out-of-pocket costs, which may be the real reason why people use “free” emergency department care.</p>
<p><strong>4) Making it clear and easy to sign up</strong></p>
<p>It is also unclear how the process of registration will work for patients. Will patients be offered a choice of alternative GPs? If chosen, will GPs be obliged to take them? </p>
<p>At the moment, there are no public data about out-of-pocket costs and quality of care provided by different GPs, and so it will be impossible for patients to make an informed choice. Information to inform choice on a website would be useful, as is the case for <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder">specialists</a>. </p>
<p>It’s also unclear if patients who chose to register will find it harder to move GPs or continue to see other GPs if they wish to. The advantages to patients of MyMedicare need to be made clear to encourage them to register and be supported to exercise informed choice if they wish.</p>
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<em>
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Read more:
<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">If you live in a bulk-billing ‘desert’ it's hard to see a doctor for free. Here's how to fix this</a>
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<h2>Will it make a difference for GPs?</h2>
<p>Patient registration can mean a more secure and predictable stream of future income for some patients and also less competition (in terms of “losing” patients to other GPs) and more continuity of care. </p>
<p>Moving away from fee for service towards a blended payment model is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011865.pub2/full">widely recognised</a> to support higher value health care. </p>
<p>Yet GPs are wary of moving from fee for service to capitation payment. Capitation payments are fixed, so GPs take on more financial risk if they have more complex patients who are more costly to treat and manage in terms of time and effort. Whether the $2,000, plus $500 bonus, plus normal fee for service payments are sufficient to cover the costs of treating very complex patients is unclear. </p>
<p>Overall, GPs will get more money, and along with the other announcements in the budget, will receive a significant investment of resources invested in primary care. </p>
<p>Our previous <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">research</a> has shown a 5% increase in earnings for GPs is predicted to reduce the total number of GPs by up to 1% (equivalent to around 310 GPs in 2021) at a time of significant GP shortages. If they get paid more, they would prefer to work less.</p>
<p>But this could also be offset because the increase in funding will hopefully make general practice more attractive as a career and so there will be more postgraduate doctors <a href="https://www.sciencedirect.com/science/article/pii/S0167629612000902">choosing to be a GP</a>. </p>
<p>Voluntary patient registration under MyMedicare has potential to strengthen the relationship between patients and their GP, and focuses on keeping patients out of hospital and properly cared for in residential aged care. But the devil is in the detail and we will need a proper evaluation to determine the impacts on health outcomes, costs and access to health care. </p>
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Read more:
<a href="https://theconversation.com/what-if-medicare-was-restricted-to-gps-who-bulk-billed-this-kind-of-reform-is-possible-203543">What if Medicare was restricted to GPs who bulk billed? This kind of reform is possible</a>
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<img src="https://counter.theconversation.com/content/206183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australian Research Council, Medibank Better Health Foundation, and the Independent Hospital and Aged Care Pricing Authority.</span></em></p>MyMedicare is a new voluntary scheme that allows patients to register with their usual GP. How will it work? And how might it benefit patients? Here’s what we know so far.Anthony Scott, Professor of Health Economics, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2096812023-07-13T20:06:13Z2023-07-13T20:06:13ZShould GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts<p>Australian of the Year and body positivity advocate Taryn Brumfitt has <a href="https://www.smh.com.au/healthcare/doctors-should-avoid-discussing-patient-s-weight-australian-of-the-year-says-20230707-p5dmhv.html">called for</a> doctors to avoid discussing a patient’s weight when they seek care for unrelated matters.</p>
<p>A 15-minute consultation isn’t long enough to provide support to change behaviours, Brumfitt says, and GPs don’t have enough training and expertise to have these complex discussions. </p>
<p>“Many people in larger bodies tell us they have gone to the doctor with something like a sore knee, and come out with a ‘prescription’ for a very restrictive diet, and no ongoing support,” Brumfitt <a href="https://www.smh.com.au/healthcare/doctors-should-avoid-discussing-patient-s-weight-australian-of-the-year-says-20230707-p5dmhv.html">told the Nine newspapers</a>. </p>
<p>By raising the issue of weight, Brumfitt says, GPs also risk turning patients off seeking care for other health concerns. </p>
<p>So should GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts.</p>
<h2>Three out of five said yes</h2>
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<img alt="" src="https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=138&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=138&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=138&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=174&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=174&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537232/original/file-20230713-25-ksqj6n.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=174&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>Here are their detailed responses:</em></p>
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<p><em>Disclosure statements: <strong>Brett Montgomery</strong> is a general practitioner. He does not have a specific interest in obesity, but like almost all GPs, he treats many patients who are overweight or obese. He is a fellow of the Royal Australian College of General Practitioners; the college’s position statement on obesity prevention and management is linked to from this article. However, Brett writes here as an individual, and not on behalf of any organisation; <strong>Emma Beckett</strong> has received funding for research or consulting from Mars Foods, NHMRC, ARC, AMP Foundation, Kellogg, and the University of Newcastle. She works for Nutrition Research Australia and member of committees/working groups related to nutrition or the Australian Academy of Science, the National Health and Medical Research Council and the Nutrition Society of Australia. Emma has lived experience of GPs bringing up her weight; <strong>Liz Sturgiss</strong> receives funding from NHMRC, RACGP Foundation, National Centre for Healthy Ageing, Victorian Health Promotion Foundation. She is an appointed committee member of the Guidelines Development Committee for the review and update of the Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia and is the co-founder of the RACGP Specific Interest Group in Poverty; <strong>Nick Fuller</strong> works for the University of Sydney and has received external funding for projects relating to the treatment of overweight and obesity. He is the author and founder of the Interval Weight Loss program; <strong>Helen Truby</strong> has received funding from the NHMRC, the MRFF, the Commonwealth Department of Health, Health and Wellbeing Qld, Clinical Therapy Research in the Specialist Health Services (KLINBEFORSK, Norway), the Andrea Joy Logan Trust, the Victorian Cancer Agency Health Services Scheme.</em> </p>
<p><em>Editor’s note: This article has been updated to include Helen Truby’s final sentence, which was erroneously cut off during layout.</em></p><img src="https://counter.theconversation.com/content/209681/count.gif" alt="The Conversation" width="1" height="1" />
Australian of the year Taryn Brumfitt has called for doctors to avoid raising the issue of weight in consultations about other matters. We asked the experts if they should – or not.Fron Jackson-Webb, Deputy Editor and Senior Health EditorLicensed 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>
</blockquote>
<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>
<hr>
<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>
<blockquote>
<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>
</blockquote>
<h2>GPs as ‘conductors of the orchestra’</h2>
<blockquote>
<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>
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<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
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<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/2071402023-06-14T12:28:41Z2023-06-14T12:28:41ZTrans and gender-diverse people in Saskatchewan need better access to primary care<figure><img src="https://images.theconversation.com/files/531890/original/file-20230614-17-ritl1a.jpg?ixlib=rb-1.1.0&rect=1116%2C41%2C5030%2C3016&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trans and gender-diverse people in Saskatchewan face challenges accessing primary care.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Research has demonstrated time and again that the social marginalization and exclusion experienced by many people who are trans and gender diverse are <a href="https://doi.org/10.1001%2Fjamanetworkopen.2020.15036">closely tied to having poorer health, including higher rates of chronic illness</a>. </p>
<p>This may be because many trans and gender-diverse people have had negative experiences with health-care providers, or feel that the health-care system is ill-equipped to handle their needs, or are on long waiting lists for care.</p>
<p>In a <a href="https://www.schoolofpublicpolicy.sk.ca/research-ideas/publications-and-policy-insight/policy-brief/access-to-quality-healthcare-for-people-who-are-trans-and-gender-diverse-in-saskatchewan.php">new policy brief</a>, we outline our concerns about access to health care for people who are trans and gender diverse in Saskatchewan. </p>
<p>This work is part of a broader initiative — <a href="https://research-groups.usask.ca/transnavigator/the-project.php">the Trans Research and Navigation Saskatchewan</a> (TRANS) project — that explores the effectiveness of peer navigation for improving the health-care experiences of trans and gender-diverse people in the province. </p>
<figure class="align-center ">
<img alt="A person in a purple T-shirt outdoors, looking at the camera," src="https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531891/original/file-20230614-22-aaakle.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">
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<span class="caption">The challenges facing people who are trans and gender-diverse begin from the moment they enter their doctor’s office.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Peer navigators are members of a community — in this case, trans and gender-diverse people — who draw on their own experiences with the medical system to help others overcome barriers to care. </p>
<p>The brief draws on the preliminary research from the project as well as existing research on the experiences of people who are trans and gender diverse in Saskatchewan and elsewhere. It focuses on barriers to primary care, barriers to specialist care and other socio-legal concerns. </p>
<h2>Challenges for trans, gender-diverse patients</h2>
<p>The challenges facing people who are trans and gender diverse begin from the moment they enter their doctor’s office. </p>
<p>In addition to concerns about the use of the right name and pronouns, some people who participated in the focus groups and interviews held by the TRANS project shared accounts of physicians refusing to provide any type of care to trans and gender-diverse people and/or refusing to refer them to another physician. </p>
<p>Given the <a href="https://globalnews.ca/news/9175996/saskatoon-clinics-close-patients/">lack of family physicians with openings for new patients in Saskatchewan</a>, this leaves some trans and gender-diverse people without a doctor. Furthermore, people whose doctors aren’t willing to provide hormone therapy may feel that the same doctor is unlikely to provide supportive knowledgeable care in other areas.</p>
<figure class="align-center ">
<img alt="stock photo of a transgender person looking at camera with blurred light background" src="https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531892/original/file-20230614-20-bb9fjr.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">People who are trans and gender diverse may face long wait lists for appointments with doctors who are comfortable providing gender-affirming care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In other instances, people who are trans and gender diverse reported that their family doctors are generally supportive, but not comfortable — at least not yet — with providing gender-affirming care including prescribing hormone therapy. </p>
<p>Yet hormone therapies are relatively straightforward prescriptions, <a href="https://theconversation.com/gender-affirming-care-has-a-long-history-in-the-us-and-not-just-for-transgender-people-201752">and similar medications</a> are often prescribed for cis-gender men with low testosterone or cis-gender women experiencing menopause. But many family doctors do not feel comfortable providing them to people who are trans and gender diverse, though the reasons for this are unclear.</p>
<p>This leaves people who are trans and gender diverse hoping that their family doctor will refer them to someone else who is comfortable providing hormone therapy. For people in rural areas — <a href="https://saisia.ca/wp-content/uploads/2022/07/Final-version-EN-Benefits-of-living-in-Rural-SK-with-crop-marks.pdf">35 per cent of the people in Saskatchewan</a> — these challenges can be compounded by the need to travel for care. </p>
<p>Given that there are very <a href="https://doi.org/10.1089/trgh.2020.0181">few family doctors who report that they <em>are</em> comfortable providing hormone therapy in Saskatchewan</a>, there are long wait lists for appointments, and people who are trans and gender diverse are left in the lurch. </p>
<h2>Solutions for improving care</h2>
<p>The solution to this problem is relatively simple: ensuring that more and more family doctors in Saskatchewan are comfortable providing gender-affirming care, including hormone therapy. </p>
<figure class="align-center ">
<img alt="A person with a beard and glasses wearing a striped shirt smiling and a second person out of focus" src="https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531893/original/file-20230614-31-dbn8gn.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">Reducing bottlenecks in primary care is a critical part of improving the health of people who are trans and gender-diverse.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>There are many ways to make this happen. The simplest and most cost-effective approach is for willing family doctors to educate themselves <a href="https://www.rainbowhealthontario.ca/TransHealthGuide/">using relevant guidelines</a> carefully developed in other provinces (or <a href="https://bmc1.utm.utoronto.ca/%7Ekelly/transprimarycare/resources.html">other training resources</a>). </p>
<p>Other options, as we outline in the policy brief, could involve family doctors connecting with others who are more experienced in providing gender-affirming care, or receiving support from the peer navigation program initially established by the TRANS research team. </p>
<p>Those involved in medical education — at the University of Saskatchewan and elsewhere — could continue to support <a href="https://www.sma.sk.ca/?tribe_events=trans-inclusive-healthcare-series">medical education opportunities</a> for family doctors and other primary-care providers to become more comfortable in providing gender-affirming care. </p>
<p>There are other straightforward and important interventions that could improve access to care. These include, among others: </p>
<ul>
<li>Continued support for the peer navigation program, </li>
<li>Changing requirements for access to surgical care, </li>
<li>Increasing the availability of mental health supports, </li>
<li>Making it easier to make changes to legal documents and identification, and </li>
<li>Establishing a multidisciplinary network or health centre dedicated to care for people who are trans and gender diverse. </li>
</ul>
<p>Improving access to family doctors who are <a href="https://doi.org/10.3390/healthcare9080967">supportive, competent and confident</a> in providing access to hormone therapy — reducing bottlenecks in primary care — is a critical part of improving the health of people who are trans and gender diverse.</p><img src="https://counter.theconversation.com/content/207140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alana Cattapan receives funding from the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Gwen Rose 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>Improving the health of people who are trans and gender diverse means improving access to family doctors who are supportive, competent and confident in providing access to gender-affirming care.Alana Cattapan, Assistant Professor, Department of Political Science, University of WaterlooGwen Rose, PhD candidate in English and research assistant with the Trans Research and Navigation Saskatchewan (TRANS) project, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045272023-05-09T23:01:37Z2023-05-09T23:01:37ZHealth budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing<p>There were four major changes for <a href="https://www.health.gov.au/resources/collections/budget-2023-24">health care in the 2023-24 budget</a>: prioritising primary care, funding to strengthen Medicare, cheaper access to common medicines, and new funding to keep the digital health system going. Many of these changes were <a href="https://federation.gov.au/national-cabinet/media/2023-04-28-strengthening-medicare">foreshadowed in recent weeks</a>.</p>
<p>The big news on budget night was a tripling of the bulk-billing incentive, a key plank to strengthen Medicare. </p>
<p>This payment was <a href="https://journals.sagepub.com/doi/abs/10.1258/1355819042349899?journalCode=hsrb">introduced in 2004</a> to encourage GPs to bulk bill pensioners, health care card holders and children. It provides an additional amount, of <a href="http://www9.health.gov.au/mbs/search.cfm?q=10990&sopt=I">around A$7</a> to <a href="http://www9.health.gov.au/mbs/search.cfm?q=10991&sopt=I">over $10</a> depending on GP location, on top of the ordinary Medicare rebate when the service is bulk billed. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1655900499101601793"}"></div></p>
<p>But bulk billing has since declined, from about 90% of attendances in early 2022 to <a href="https://www.health.gov.au/resources/publications/medicare-quarterly-statistics-state-and-territory-december-quarter-2022-23?language=en">about 80% a year later</a>. Bulk billing is unevenly distributed and in some low-income areas (<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">bulk-billing deserts</a>) fewer than 50% of people have all their GP attendances bulk billed. This causes uncertainty and people missing out on care.</p>
<p>A tripling of the bulk-billing incentive – described as the biggest investment in Medicare in 40 years – is hoped to stem, and possibly reverse, the decline. </p>
<p>However it’s unclear whether it will increase bulk billing. Practice owners could simply pocket the increased incentive for patients who are already bulk billed, leaving bulk billing rates unchanged. Or GPs could use the increased revenue from their existing bulk-billed patients to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">reduce their hours of work</a>, rather than bulk billing more patients.</p>
<h2>1. Primary care is now a priority</h2>
<p>The most important change in the budget for health was symbolic: the government talked about primary care. Typically, health budgets are focused on hospitals, with primary care an afterthought, or worse: the target of budget cuts. </p>
<p>The 2023 budget starts the process of the primary care rebuild, modernising the system in response to the transition to a population with more people with multiple chronic conditions, such as diabetes, heart disease and depression.</p>
<p>In the lead up to the budget, Health Minister Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023?language=en">emphasised the centrality of primary care</a> to the health system. In addition to the rhetoric, this budget allocates real money to create a new foundation for primary care.</p>
<h2>2. Funding the plan to strength Medicare</h2>
<p>The second change is to fund what has been long discussed. Health Minister Butler signalled the focus on primary care as one of his first acts when he appointed the <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce">Strengthening Medicare Taskforce</a>, which I was a member of. </p>
<p>The <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">taskforce report</a>, released late last year, sets out an ambitious blueprint for change. This budget includes the first down payment, of more than $1 billion new money in a full year. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-medicare-reforms-wont-fix-everything-but-they-start-to-tackle-the-systems-biggest-problems-204800">New Medicare reforms won't fix everything but they start to tackle the system's biggest problems</a>
</strong>
</em>
</p>
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<p>A key challenge for primary care policy is the reliance on fee-for-service payments. The budget addresses this by modernising the way the government pays for primary care in two critical ways:</p>
<p><strong>Patient enrolment</strong> </p>
<p>First, it introduces the concept of enrolment into the Australian primary care world. </p>
<p>Long part of primary care systems internationally, and regarded as one of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948764/">key “building blocks” for good primary care</a>, enrolment involves a patient identifying a preferred GP as their main source of care. </p>
<p>Patient enrolment, dubbed MyMedicare, will mean the practice or GP has responsibility for the patient between visits, and therefore introduces a long-term relationship between patient and practitioner.</p>
<p><strong>Team-based health care</strong></p>
<p>The Strengthening Medicare Taskforce also recommended more multi-disciplinary or team-based primary care, involving nurses, physiotherapists and a range of other health providers and administrative supports. This is a somewhat back-to-the-future initiative as the 21st-century iteration of the <a href="https://www.sydney.edu.au/news-opinion/news/2014/11/05/whitlam--medibank-and-health-system-reform.html">Whitlam government’s community health program</a>.</p>
<p>The budget provides a significant increase in the <a href="https://www.health.gov.au/our-work/workforce-incentive-program">workforce incentive program</a>, which provides grants to practices to employ nurses, Aboriginal and Torres Strait Islander health workers and allied health professionals. </p>
<p>The program recognises that care for people with multiple chronic conditions requires the skills of a range of professions. Importantly, many general practices have already recognised this and are already providing team-based care.</p>
<p>The increased funding in this budget will reward that past behaviour, making these practices more viable, as well as encouraging an expansion in other practices.</p>
<figure class="align-center ">
<img alt="Clinician takes an elderly man's blood pressure with a machine" src="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.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 changes emphasise team-based care, using the skills of a range of health providers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-man-having-blood-pressure-check-2246991347">Shutterstock</a></span>
</figcaption>
</figure>
<h2>3. Extended prescription dispensing length</h2>
<p>The third budget change, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">announced in April</a>, reduces prescription costs for medications by extending prescription quantities to two rather than one month’s supply for many common medications. </p>
<p>Despite <a href="https://www.smh.com.au/business/small-business/chemists-cry-poor-after-the-cornucopia-of-covid-19-20230427-p5d3nr.html">the tears and histrionics</a> of the Pharmacy Guild – the lobby group of pharmacy owners – the expert <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2018-08/Increased-Dispensing-Quantity-List-of-Medicines-8-April-2019.pdf">Pharmaceutical Benefits Advisory Committee</a> recommended this modest change five years ago. </p>
<p>It doubles the amount of medication that may be dispensed under a single prescription, reducing patient co-payments and dispensing fees paid to pharmacists. It reduces government outlays by about $400 million a year and shows the government is prepared to take on a powerful stakeholder, despite the guild’s threats, <a href="https://www.afr.com/politics/federal/anthony-pratt-donates-nearly-4m-to-major-parties-20230130-p5cgn2">big political donations</a> and local campaigns. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1653165234155134976"}"></div></p>
<h2>4. Digital health time bomb</h2>
<p>Finally, the budget addresses a time bomb left by the previous government: digital health. </p>
<p>The Strengthening Medicare Taskforce identified contemporary digital health capacity as essential for a modern health system. Yet peculiarly, the previous government did not provide funding for the Digital Health Agency and My Health Record on an ongoing basis. It was due to expire on June 30 2023. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-health-record-is-meant-to-empower-patients-but-with-little-useful-information-stored-is-it-worth-saving-199508">My Health Record is meant to empower patients – but with little useful information stored, is it worth saving?</a>
</strong>
</em>
</p>
<hr>
<p>Some $250 million has been allocated in a full year <a href="https://www.medicalrepublic.com.au/whats-new-is-old-is-new-again-in-budget/91016">simply to keep the lights on and My Health Record ticking over</a>. </p>
<p>Although the current functionality and support for My Health Record leaves much to be desired, closing it down without replacement was never an option.</p>
<h2>What’s missing?</h2>
<p>The obvious omission relates to mental health. Although funding has been provided for more budget time bombs – programs which otherwise would have ended – and funding for additional places in psychology courses, mental health reform is still a work in progress.</p>
<p>The discontinuation of the COVID-related temporary extension of the Better Access program from a limit of ten to a limit of 20 mental health visits prompted <a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">predictable criticism</a>, even though the program was <a href="https://insightplus.mja.com.au/2023/3/governments-better-access-initiative-must-change-to-prevent-a-mental-health-crisis/">demonstrably inequitable</a>. The government has recognised this gap, titling its mental health budget announcement “<a href="https://www.health.gov.au/resources/publications/laying-the-groundwork-for-mental-health-and-suicide-prevention-system-reform-budget-2023-24?language=en">laying the groundwork</a>”. </p>
<p>Overall, the health component of the 2023-2024 budget is well crafted. It signals a new priority for primary care and provides a new foundation for funding reform for the future. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/204527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is Chair of the Board of Directors of Eastern Melbourne Primary Health Network and was a member of the Strengthening Medicare Taskforce </span></em></p>The big news on budget night was a tripling of the bulk-billing incentive. It’s hoped to stem the decline in bulk billing – but it’s unclear if it will increase it.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2035612023-04-18T20:01:47Z2023-04-18T20:01:47ZMedicare billing is a problem but our research found many more GPs undercharge<figure><img src="https://images.theconversation.com/files/520646/original/file-20230413-18-4oyane.jpg?ixlib=rb-1.1.0&rect=68%2C53%2C5002%2C3327&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-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span></figcaption></figure><p>Australia’s Medicare billing system is overly complicated, bureaucratic and not meeting the needs of a modern health service, potentially leaking billions of dollars. But claims this loss is mostly due to fraudulent billing practices by GPs are inaccurate. </p>
<p>In October, the ABC’s 7.30 program and the Nine newspapers <a href="https://www.smh.com.au/politics/federal/medicare-is-haemorrhaging-the-rorts-and-waste-costing-taxpayers-billions-of-dollars-a-year-20221013-p5bpp9.html">raised concerns</a> about an estimated A$8 billion in Medicare waste, caused by a mixture of doctors’ errors, over-servicing and outright fraud. The examples given, however, were almost exclusively intentional fraud, mainly in general practice. This promoted health minister Mark Butler to commission an <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/independent-review-into-medicare-compliance">independent review</a>, led by Dr Pradeep Philip.</p>
<p>The <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">Philip review</a>, released earlier this month, was highly critical of the current Medicare system and found non-compliance and fraud accounted for $1.5 to $3 billion of Medicare waste.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1643122020585029632"}"></div></p>
<p>Our research team <a href="https://www1.racgp.org.au/ajgp/2023/april/general-practitioner-charging-of-medicare">analysed GP activity</a> recorded during almost 90,000 patient encounters to assess how GPs were billing for the services they provided. </p>
<p>We found GPs undercharged at 11.8% of encounters and overcharged at 1.6%. This suggests GPs aren’t routinely defrauding Medicare, and in fact have saved the system equivalent to $351 million in the 2021-22 financial year. </p>
<p>However, we agree the current billing system needs to be urgently reformed.</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>
<h2>How does Medicare billing work?</h2>
<p>GPs claim a fee for service, called a rebate, which is a fixed amount ascribed on the Medicare Benefits Schedule (MBS), based on the type of service provided. </p>
<p>There are nearly 6,000 MBS item numbers. GPs can charge for one or more MBS items for a patient service. </p>
<p>Around 90% of MBS items claimed by GPs are considered standard consultation items (surgery, residential aged care facility visits, home visits and so on), that are in four levels (A, B, C and D) which increase in length. </p>
<p>The cost associated increases with each level. An example of an error would be a GP accidentally charging for a Level C consultation (requires 20 minutes or longer; $76.95 rebate) when the visit only met the criteria for a Level B (less than 20 minutes; rebate of $39.75). An example of under-billing is when a GP is entitled to claim for a Level C but charges only a Level B. </p>
<p>An example of over-servicing is a pathology test for blood glucose level being repeated for the same patient at consecutive visits, where the patient’s condition did not warrant the second test. </p>
<p>An example of fraud would be claiming for a service that had not been provided.</p>
<figure class="align-center ">
<img alt="patients wait in a GP clinic waiting room" src="https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.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">
<figcaption>
<span class="caption">Rebates are based on the time spent with the patient.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woodbridge-suffolk-6-july-2021-people-2003258147">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Examining doctors’ billing in the real world</h2>
<p>The data we analysed in our peer-reviewed <a href="https://www1.racgp.org.au/ajgp/2023/april/general-practitioner-charging-of-medicare">study</a> were collected between 2013-2016 from nationally representative samples of GPs during 89,765 real-time encounters with their patients. The GPs recorded the start and finish time for each visit. </p>
<p>The Philip review did not try to quantify the amount of underbilling. </p>
<p>We decided to examine the billing data following the 7.30 Report/Nine news investigation, but the participants could not have been influenced by these reports as the data we used were collected prior to the ABC/Nine publications.</p>
<h2>Why would doctors undercharge?</h2>
<p>We theorised GPs were likely undercharging Medicare for two reasons:</p>
<p>1) while time is the predominant measure, GPs are likely to still consider content and complexity when billing standard Medicare items, rather than just billing according to the time spent with the patient</p>
<p>2) fear of triggering a professional services review (PSR) of their billing.</p>
<p>A professional services review can be triggered for a variety of reasons, for example, a GP has a higher proportion of longer consultations than might be expected. A professional services review involves an audit of the GP’s billing. It can potentially lead to a decision that can prevent the GP from being able to bill Medicare.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/6-reasons-why-its-so-hard-to-see-a-gp-199284">6 reasons why it's so hard to see a GP</a>
</strong>
</em>
</p>
<hr>
<p>Last week, <a href="https://www.healthed.com.au/">HealthED</a>, a health education company, included three post-webinar questions on this topic in an online survey of 1,852 GPs from across Australia. Answering these questions was not compulsory.</p>
<p>The results showed most (83.3%) GPs consider the length and complexity of the consultation when billing Level C and D items, even though increased complexity is no longer required (since 2011).</p>
<p>More than half (60.3%) intentionally under-billed Medicare in the previous week. </p>
<p>The most common reasons for under-billing were:</p>
<ul>
<li><p>they did not feel that the content of the consultation justified a higher MBS item (41.9%)</p></li>
<li><p>fear of triggering a professional services review alert (33.5%)</p></li>
<li><p>confusion around Medicare schedule criteria (30.8%).</p></li>
</ul>
<p>These responses correlate with the findings from our nationally representative sample, which suggests GPs predominantly act with integrity, but also based on fear and confusion.</p>
<h2>Time to reform Medicare billing</h2>
<p>A simplification of the current very complex Medicare billing system would resolve a lot of waste through unintended errors. Reducing low value and unnecessary care is not a simple task as these are difficult to define, and often rely on situational judgement. When systems are no longer fit for purpose, they should be reviewed and revised, as the Philip review has recommended.</p>
<p>There are bad actors in every profession and those who “game” Medicare should be called out. However, the claims of widespread fraud have not been supported by our work or the Philip review.</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>
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</p>
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<img src="https://counter.theconversation.com/content/203561/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>New research suggests GPs aren’t routinely defrauding Medicare, and in fact have saved the system hundreds of millions of dollars by under-billing.Christopher Harrison, Senior Lecturer, Sydney School of Public Health, University of SydneyJoan Henderson, Senior Research Fellow (Hon), University of Sydney. Editor, Health Information Management Journal (HIMJ), University of SydneyMelissa Kang, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1969662023-01-27T11:59:40Z2023-01-27T11:59:40ZEarwax removal no longer available at GP surgeries – leaving many struggling to hear<figure><img src="https://images.theconversation.com/files/506314/original/file-20230125-24-dh3ts5.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6497%2C4325&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/horizontal-shot-frustrated-young-caucasian-female-1950619960">Anatoliy Karlyuk/Shutterstock</a></span></figcaption></figure><p>Each year, more than <a href="https://doi.org/10.1093/qjmed/hch082">2 million people in the UK</a> have troublesome earwax that needs to be removed. However, more people are finding that this service is no longer being provided at their GP surgery. In fact, 66% of people seeking these services have been told that earwax removal is <a href="https://rnid.org.uk/wp-content/uploads/2022/11/Ear-Wax-Report-FINAL.pdf">no longer available on the NHS</a>.</p>
<p><a href="https://questions-statements.parliament.uk/written-questions/detail/2020-09-15/90063">Questions have been raised in parliament</a> about why people are being referred to earwax clinics in hospitals. This results in long waiting times and is not the best use of specialist services. </p>
<p>Many people are resorting to using private services on the high street that cost around £50 to £100. But the Royal National Institute for Deaf People (RNID), a charity, reports that more than a quarter of people they surveyed <a href="https://rnid.org.uk/wp-content/uploads/2022/11/Ear-Wax-Report-FINAL.pdf">cannot afford to pay</a> to have their earwax removed privately. This especially applies to people requiring recurrent earwax removal, such as those who wear hearing aids and earbud earphones – which tend to cause impacted earwax.</p>
<p>Our bodies produce earwax to clean, protect and keep our ears healthy. Movement of the jaw, as well as the skin that lines the ear canal, causes the wax to move to the entrance of the ear where it then flakes off or is carried away when we wash. Sometimes this doesn’t work and the earwax becomes impacted. Impacted earwax that blocks the ear canal is a major reason for GP consultations.</p>
<p>The National Institute for Health and Care Excellence (Nice) is clear that NHS earwax removal <a href="https://www.nice.org.uk/guidance/ng98/chapter/Recommendations#removing-earwax">services should be provided in the community</a> where demand is greatest. Why is this recommendation for community earwax removal services falling on deaf ears? </p>
<p>A recommendation from Nice is not a mandate, and GPs are under no obligation to offer an earwax removal service. There are several reasons this service is often no longer offered in primary care, some of which are based on misunderstandings.</p>
<p>First, manual water-filled syringes for flushing out earwax can cause high pressure of water and might damage the patient’s ears – not something a GP wants to be responsible for doing. (Alternative cheap, low-pressure water irrigation devices are now widely available.) </p>
<p>Second, there is a mistaken belief among some GPs that earwax can be self-managed using wax-softening ear drops on their own. However, there is <a href="https://www.nice.org.uk/guidance/ng98">no good quality evidence</a> that softened earwax dissolves and magically disappears into the ether.</p>
<h2>Effects of impacted earwax</h2>
<p>The <a href="https://bjgp.org/content/73/727/90">most common symptom</a> caused by impacted earwax is hearing difficulty. This is often accompanied by discomfort and noises in the ears. <a href="https://healthwatchoxfordshire.co.uk/summarised-reports/getting-treatment-for-earwax-and-hearing-problems-in-oxfordshire/">Healthwatch Oxfordshire</a>, a charity, revealed that adults with earwax required between one and four NHS visits before attending a dewaxing clinic and that the time from first experiencing symptoms to final resolution was three to 30 weeks. </p>
<p>Try simulating the effect of impacted wax by walking around with your fingers firmly plugging both of your ears for a few days. You’ll soon realise that what at first sounds trivial is no laughing matter.</p>
<p>Hearing difficulty means you can’t communicate with ease or listen to the TV. It also reduces your ability to detect and monitor sounds in the environment, such as an approaching car. Hearing difficulty can lead to <a href="https://www.nice.org.uk/guidance/ng98">social isolation and depression</a>. More than <a href="https://doi.org/10.3399/bjgp23X732009">nine out of ten people</a> report that impacted earwax was at least moderately bothersome to them, and 60% said it is very or extremely bothersome.</p>
<p><a href="https://www.nice.org.uk/guidance/ng98/chapter/Recommendations#removing-earwax">Nice recommends</a> that impacted earwax is removed by irrigating the ear with the newer, safer low-pressure water irrigation devices, or microsuction to hoover it up. When questioned, most people <a href="https://doi.org/10.3399/bjgp23X732009">do not have a preference</a>, although some report that water irrigation is messy and others that microsuction causes discomfort and is noisy.</p>
<p>Removal of earwax in health centres using microsuction results in levels of <a href="https://doi.org/10.3399/bjgpopen19X101649">patient satisfaction</a> that are at least as good as those provided in a hospital.</p>
<p>Before removal, pre-treatment drops or sprays are used to soften the earwax. These are applied daily for up to five days before removal. There is a vast array of pre-treatment earwax softening products, but <a href="https://www.nice.org.uk/guidance/ng98/chapter/Recommendations#removing-earwax">none are better than any other</a>. As a result, most people use olive oil, which can be administered as drops or as a spray.</p>
<p>There are a variety of self-administered, earwax management products on the market but the evidence for these is limited and <a href="https://www.nice.org.uk/guidance/ng98/chapter/Recommendations#removing-earwax">none are currently recommended by Nice</a>. An example is the use of Hopi ear candles or cones. To use these, you lie with your head on one side and place the lit candle in the upward-facing ear. </p>
<p>These are reported to work by softening the wax and then sucking it out of the ear canal and up the cone like a chimney. There is <a href="https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599816671491">no evidence</a> to support this claim. These candles and cones cost money and are ineffective.</p>
<figure class="align-center ">
<img alt="The author, Kevin Munro, trying Hopi ear candles." src="https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506534/original/file-20230126-22936-u4nv53.jpg?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">
<figcaption>
<span class="caption">The author, Kevin Munro, tries Hopi ear candles.</span>
<span class="attribution"><span class="source">Kevin Munro</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>How it could be done</h2>
<p>If individual GP surgeries lack the expertise or funding to provide earwax removal services, an alternative is for groups of practices to collaborate as a network. The portable nature of modern wax removal equipment is ideal in such settings and for use in home visits. This approach could be especially valuable for vulnerable people, such as those in care homes where <a href="https://doi.org/10.1016/j.jamda.2022.07.011">44% of residents with dementia also have impacted earwax</a>.</p>
<p>In the meantime, the withdrawal of NHS earwax removal services is having a <a href="https://rnid.org.uk/wp-content/uploads/2022/11/Ear-Wax-Report-FINAL.pdf">far-reaching impact</a>, with people experiencing bothersome and distressing symptoms, sometimes leading to poor mental health.</p><img src="https://counter.theconversation.com/content/196966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Munro 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>Impacted earwax that blocks the ear canal is a major reason for GP consultations.Kevin Munro, Ewing Professor of Audiology, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1968662022-12-21T22:27:25Z2022-12-21T22:27:25ZLooking forward into the past: Lessons for the future of Medicare on its 60th anniversary<figure><img src="https://images.theconversation.com/files/502285/original/file-20221221-13-qhlr9y.jpeg?ixlib=rb-1.1.0&rect=36%2C51%2C1595%2C1003&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Former Saskatchewan Premier and national New Democratic Party leader T.C. (Tommy) Douglas in 1965. Douglas was instrumental in the creation of Medicare.</span> <span class="attribution"><span class="source">The Canadian Press</span></span></figcaption></figure><p>It is the <a href="https://esask.uregina.ca/entry/medicare.jsp">60th anniversary</a> of Medicare, but no one seems to care.</p>
<p>It is, after all, hard to be enthusiastic about a system in crisis. Patients can’t find doctors (<a href="https://angusreid.org/canada-health-care-family-doctors-shortage/">almost one in five Canadian adults</a>). Those who have doctors have a hard time getting in to see them (<a href="https://angusreid.org/canada-health-care-family-doctors-shortage/">only 18 per cent can get an appointment within a day or two</a>). </p>
<p>Doctors are burned out, <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">leaving their practices with no one to replace them</a>. New physicians want to focus on patient care, <a href="https://thestarphoenix.com/opinion/columnists/murray-mandryk-sask-family-doctor-shortage-requires-new-approach/wcm/fcc52f2e-16df-4f34-84b1-8459a8552d40">not the business of health care</a>. </p>
<p>This is, of course, just the beginning of the problem. The premiers want more money from Ottawa and Ottawa wants more data from the provinces. <a href="https://calgary.ctvnews.ca/premier-under-fire-for-health-savings-account-comments-calls-it-spin-1.6162665">Alberta is making health proposals that some say are a short step away from privatized health care</a>, and the <a href="https://www.cbc.ca/news/politics/health-care-funding-premiers-federal-government-1.6644857">recent meeting between federal and provincial health ministers</a> ended in a stalemate.</p>
<h2>The dawn of Medicare</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man at a podium gesturing with his hand, and a line of people in business clothes behind him, with provincial flags" src="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.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">B.C. Health Minister Adrian Dix, right, is flanked by his provincial and territorial counterparts as he responds to questions at a news conference without federal Health Minister Jean-Yves Duclos after the second of two days of meetings, in Vancouver on Nov. 8.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>These seem like intractable problems. But our research suggests part of the solution might be found back in 1962, when the model that would grow into our current health-care system was launched in Saskatchewan, spreading to other provinces over the next few years.</p>
<p>At the dawn of Medicare, the proposed new model resulted in a strike by Saskatchewan doctors worried about “socialized medicine.” </p>
<p>Faced with the prospect of losing access to their doctors, almost 15,000 families (representing 50,000 people) formed 34 community clinic associations, raising over $325,000 (almost $3 million today) over less than a year for <a href="https://harvest.usask.ca/handle/10388/etd-04122010-091353">health-care clinics</a> that patients would own and govern based on <a href="https://www.ica.coop/en/whats-co-op/co-operative-identity-values-principles">democratic co-operative principles</a>.</p>
<p>The clinics adopted a philosophy of care that rejected many of the tenets of conventional medicine, which <a href="https://www.uregina.ca/library/services/archives/collections/faculty-staff/rands.html">Stan Rands</a>, a clinic organizer, described as focused on “physiological and biochemical causes of disease” and dependence on “equipment and tests for the diagnosis and treatment of illness.” The result, he argued, was that it was “<a href="https://www.academia.edu/8520847/Privilege_and_Policy_A_History_of_Community_Clinics_in_Saskatchewan_by_Stan_Rands">ill-equipped to deal with the human and social manifestations of illness or disease</a>.”</p>
<h2>The community co-operative clinic model</h2>
<p>Based on this philosophy, the clinics implemented what were, at the time, radical measures. Instead of being paid on a fee-for-service basis, doctors were paid salaries. Instead of sole practitioner businesses, doctors worked as part of a team deeply engaged and responsive to their communities because the clinics were run by patients. Instead of treating symptoms, the team treated patients holistically, probing the physical and <a href="https://drgabormate.com/book/the-myth-of-normal/">social factors</a> that we now know lead to illness.</p>
<p>Although the clinics strengthened the government’s hand in reaching a settlement with the striking doctors, <a href="https://harvest.usask.ca/handle/10388/etd-04122010-091353">the province never embraced the co-operative clinic model</a>. Instead, the clinics would spend years struggling to be understood by policymakers who tended to favour a conventional system based on fee-for-service, doctor-led Medicare. </p>
<figure class="align-center ">
<img alt="A woman in a white coat, stethoscope and face mask talking to a woman and child in face masks, with a man in a white coat in the background" src="https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.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">Community co-op clinics are run by patients instead of sole practitioners. Doctors work as part of a team deeply engaged and responsive to their communities.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Many clinics folded shortly after Medicare was introduced; today, only four remain, with large clinics in <a href="https://www.saskatooncommunityclinic.ca/our-coop-model/">Saskatoon</a>, <a href="https://www.reginacommunityclinic.ca/about-rcc/">Regina</a> and <a href="https://www.coophealth.com/coop-model">Prince Albert</a>, and one smaller rural clinic operating in Wynyard. Even the 2002 <a href="https://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf">Commission on the Future of Health Care in Canada</a>, led by former NDP premier of Saskatchewan Roy Romanow, ignored the sector’s efforts to put its model on the agenda.</p>
<p>Away from the spotlight, the remaining co-operative clinics went about living their philosophy. They hired social workers, offered mental health services, brought in physiotherapists, set up pharmacies, offered in-house minor surgeries, performed house calls, operated forerunners to modern-day telehealth, and set up shop in disadvantaged, poorly served communities like Saskatoon’s west side.</p>
<h2>The future of co-op clinics</h2>
<p>Meanwhile, there are signs that the philosophy of team-based, patient-focused, community-based care may be gaining ground. In 2017, for example, Ontario’s <a href="http://www.matawa.on.ca/corporations/matawa-health-co-operative/">Matawa First Nation</a> opened the country’s first <a href="http://www.matawa.on.ca/corporations/matawa-health-co-operative/">Indigenous-run co-operative clinic</a>. </p>
<p>The provincial government in Ontario operates a large network of <a href="https://www.allianceon.org/news/Association-Ontario-Health-Centres-now-Alliance-Healthier-Communities">not-for-profit community clinics</a> similar in structure to Saskatchewan’s clinics but lacking explicit democratic co-operative control. In addition, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">some Canadian doctors</a> are now advocating for a different model.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-doctor-wont-see-you-now-why-access-to-care-is-in-critical-condition-169818">The doctor won't see you now: Why access to care is in critical condition</a>
</strong>
</em>
</p>
<hr>
<p>Elsewhere, there are indications that citizens may be tired of waiting for policymakers to act. As the <em>Globe and Mail</em> recently <a href="https://www.theglobeandmail.com/canada/article-how-a-small-community-on-vancouver-island-responded-to-a-looming/">reported</a>, residents of the Saanich Peninsula, on the southeast coast of Vancouver Island, raised money to open two medical clinics and recruit doctors who could take over from physicians at, or near, retirement. As Dale Henley, the co-chair of the non-profit that owns and operates the clinics told the <em>Globe and Mail</em>, </p>
<blockquote>
<p>“I think we’ve got to do a little more ourselves. We can’t just keep looking at governments all the time, because they’re not that good at it.”</p>
</blockquote>
<p>As we look back on 60 years of Medicare and contemplate its many challenges, it may be time for communities to heed Henley’s call and once again voice their desire in words and action for access to the kind of holistic care pioneered by the co-operative clinics. Maybe this time, policymakers will listen.</p><img src="https://counter.theconversation.com/content/196866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc-Andre Pigeon is the director of the Canadian Centre for the Study of Co-operatives. It receives funding from the co-operative
and credit union sector. The research into the co-operative clinics is funded, in part, by the Saskatoon Community Clinic, one of the clinics being investigated in this research. </span></em></p><p class="fine-print"><em><span>Natalie Kallio is a Professional Research Associate at the Canadian Centre for the Study of Co-operatives, which receives funding from the co-operative and credit union sector. This research is funded, in part, by the Saskatoon Community Clinic, one of the clinics being studied.</span></em></p><p class="fine-print"><em><span>Haizhen Mou 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>At the dawn of Medicare, Saskatchewan’s community co-op clinics pioneered team-based, holistic care. Now, with the health system in crisis 60 years later, it may be time to return to that care model.Marc-Andre Pigeon, Assistant Professor, Johnson Shoyama Graduate School of Public Policy, University of SaskatchewanHaizhen Mou, Professor, Johnson Shoyama Graduate School of Public Policy, University of SaskatchewanNatalie Kallio, Professional Research Associate, Canadian Centre for the Study of Co-operatives, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1941542022-11-28T00:56:26Z2022-11-28T00:56:26ZMore businesses are offering online medical certificates and telehealth prescriptions. What are the pros and cons?<figure><img src="https://images.theconversation.com/files/495294/original/file-20221115-22-kets3u.jpg?ixlib=rb-1.1.0&rect=36%2C45%2C5970%2C3944&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/young-male-doctor-telehealth-concept-600w-1456779692.jpg">Shutterstock</a></span></figcaption></figure><p>Telehealth has played an <a href="https://journals.sagepub.com/doi/10.1177/1357633X20916567">important role during the pandemic</a>. Telephone and online consultations have enabled social distancing and kept patients and clinicians safe from transmissible infections. </p>
<p>Since the start of COVID in March 2020, there have been <a href="https://coh.centre.uq.edu.au/telehealth-and-coronavirus-medicare-benefits-schedule-mbs-activity-australia">122 million telehealth consultations</a> funded through Medicare. About 90% of these services were provided by general practitioners (GPs), with <a href="https://www.publish.csiro.au/AH/AH20183">nine out of ten</a> of these consults done as a telephone call. </p>
<p>Online services for prescriptions and medical certificates have become available to consumers at the click of a button. Given the <a href="https://www.abc.net.au/news/2022-10-06/gps-turning-away-from-medicine-as-pressures-mount/101505626">shortage of GPs</a>, difficulties getting timely appointments, and clinic restrictions if patients have COVID-like symptoms, consumers seem to be welcoming these services. Patients can consult a GP by telephone or video call, and then receive an electronically dispatched medical certificate or prescription (if clinically appropriate). </p>
<p>These services are either paid for partially, or totally by the consumer, with <a href="https://www.health.gov.au/health-alerts/covid-19/coronavirus-covid-19-advice-for-the-health-and-disability-sector/providing-health-care-remotely-during-the-covid-19-pandemic">limited Medicare rebates available</a>. They are fast, convenient and readily available. But what do consumers need to know about their pros and cons? </p>
<h2>On the plus side…</h2>
<p><strong>Convenience</strong> </p>
<p>Offering services online means ease of access and convenience. We have seen this in the banking, retail and travel industries. Who wants to wait three days for a GP appointment, spend two hours in traffic and one hour in the waiting room, for a short consultation? </p>
<p><strong>Access to care</strong> </p>
<p>When providing health services, we have to think of our whole population (see points below on equity). These instant services offer greater convenience and benefits for those who find it hard to access transport, are time-poor, or who find it difficult to leave the house (such as parents of little kids or people with other physical disabilities or mental health concerns). </p>
<p><strong>Reduced wait times</strong> </p>
<p>If it isn’t possible to get an appointment with your regular GP and you need a medical certificate for work, these services may be a good fit. They also enable acute conditions to be managed in a timely manner, for instance by getting a script for tablets to stop vomiting. </p>
<p><strong>Reducing congestion in hospitals and medical centres</strong> </p>
<p>These services also <a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">reduce pressure</a> on primary care services and hospitals. If someone can be supported by an online service instead of visiting an emergency department or urgent care centre, then the bricks-and-mortar hospitals, clinics and medical centres remain available for people with more serious health needs. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman comfort child while on phone" src="https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495296/original/file-20221115-17-vj95us.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 might get a quicker telehealth appointment, but complex conditions might require an in-person consult.</span>
<span class="attribution"><a class="source" href="https://images.pexels.com/photos/8376257/pexels-photo-8376257.jpeg?auto=compress&cs=tinysrgb&w=1260&h=750&dpr=2">Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<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>
</strong>
</em>
</p>
<hr>
<h2>But there are also downsides</h2>
<p><strong>Continuity of care</strong> </p>
<p>The downside is you may risk losing continuity of care, as you are not necessarily going to be seeing your own GP online. If you have complex health needs or chronic conditions, it is better you have a primary care provider who knows your history and can manage your health condition holistically. </p>
<p><strong>Access to a complete health history</strong> </p>
<p>Australia doesn’t yet have a single complete and integrated information system for sharing all personal health information. So when you access these services, it is often your responsibility to share health information with the provider and also inform your GP about your online appointment. </p>
<p>However, communication systems are improving slowly, and a summary may be shared electronically with your nominated GP after your consultation. For patients who have opted in to <a href="https://www.myhealthrecord.gov.au/for-you-your-family">My Health Record</a>, some of this communication will happen automatically. </p>
<p><strong>Complex conditions</strong> </p>
<p>There are limits to the types of services that can be provided online or by phone. You may need an in-person appointment, especially if a physical assessment is required, or the concerns are more complex than anticipated. GPs adhere to <a href="https://www.racgp.org.au/running-a-practice/practice-standards">guidelines and practice standards</a> irrespective of how services are delivered. For instance, provision of e-scripts and medical certificates require documentation and screening measures to ensure appropriate care is provided.</p>
<p><strong>Medications</strong> </p>
<p>Online or telehealth services aren’t suited for starting new medications that require monitoring or might have side effects. </p>
<p>New medications for chronic conditions should ideally be started by someone who you can see you again to check they are working and manage potential side effects or reactions. Additionally, there are medications (such as strong pain relief) these services won’t prescribe, and consumers need to see an GP in person to obtain. </p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<h2>Medical certificates aren’t just for your boss</h2>
<p>Local pharmacists can write medical certificates for single days and assist with advice and medications for minor health issues. However, they cannot write prescriptions.</p>
<p>The aim of a medical certificate is to satisfy an employer. But getting a medical certificate may also be an opportunity to have symptoms checked and make sure there is nothing seriously wrong. </p>
<p>Online services make accessing a medical certificate for the flu or gastro much more convenient. However, if people are having ongoing health issues that require regular time away from work, they should be seeing a regular GP to help manage their condition. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-after-hours-and-i-need-to-see-a-doctor-what-are-my-options-190144">It’s after-hours and I need to see a doctor. What are my options?</a>
</strong>
</em>
</p>
<hr>
<h2>Online doesn’t mean equal access</h2>
<p>There is the risk of inequity of access for these services, especially for consumers who don’t know how to access them, can’t afford to pay, or do not have access to the necessary technology (including reliable internet).</p>
<p>A <a href="https://journals.sagepub.com/doi/full/10.1177/1357633X221107995">recent paper</a> suggested ways to tackle this digital divide. These included improving digital health literacy, workforce training, co-designing new models of care with clinicians and patients, change management, advocacy for culturally appropriate services, and sustainable funding.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="person holding blister pack of yellow capsules" src="https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/496647/original/file-20221122-23-c1u58b.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">Strong painkillers won’t be prescribed online.</span>
<span class="attribution"><a class="source" href="https://images.pexels.com/photos/3873191/pexels-photo-3873191.jpeg?auto=compress&cs=tinysrgb&w=1260&h=750&dpr=2">Pexels/Polina Tankilevitch</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Other points to remember</h2>
<p>Finally, consumers need assurance that health services are provided by suitably qualified health professionals. This is usually achieved with confirmation of health provider credentials prior to, or at the start of, the consultation. </p>
<p>Consumers can also look up their provider through the <a href="https://www.ahpra.gov.au/registration/registers-of-practitioners.aspx">Australian Health Practitioner Regulation Agency (Ahpra)</a> where all clinicians are registered. </p>
<p>Consumers should also look for an Australian service to ensure it adheres to Australia’s quality standards and clinician registration criteria. This is also important because of the Australian standards around personal data collection and storage. Consumers should read information provided by services about their data policies. </p>
<p>As with all health care, it is about finding the right balance and ensuring services align with clinical indications. </p>
<p>Telehealth is not about replacing in-person appointments. Telehealth should be used in conjunction with face-to-face advice, to <a href="https://doi.org/10.3399/bjgpo.2021.0182">maintain high-quality care</a> that best suits the needs and wishes of the consumer.</p><img src="https://counter.theconversation.com/content/194154/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>Online and phone consultations might ease pressure on local clinics and mean you can access paperwork when visiting a GP isn’t possible. But there are downsides to be aware of too.Centaine Snoswell, Research Fellow Health Economics, The University of QueenslandAnthony Smith, Professor of Telehealth; and Director of the Centre for Online Health, The University of QueenslandKeshia De Guzman, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1895092022-11-18T13:31:40Z2022-11-18T13:31:40ZDoctors often miss depression symptoms for certain groups – a routine screening policy for all adult primary care patients could significantly reduce the gap<figure><img src="https://images.theconversation.com/files/495727/original/file-20221116-20-p9ujg0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2000%2C1500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Depression is a leading cause of disability worldwide.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-patient-sitting-on-exam-table-in-clinic-room-royalty-free-image/114147001">Thomas Barwick/Stone via Getty Images</a></span></figcaption></figure><p>Depression is a costly and debilitating condition that profoundly influences a person’s quality of life. In 2020, <a href="https://www.nimh.nih.gov/health/statistics/major-depression">more than 21 million adults</a> in the U.S. reported having at least one major depressive episode in the previous year. Depression symptoms increased dramatically during the COVID-19 pandemic, and now affect nearly <a href="https://doi.org/10.1016/j.lana.2021.100091">1 in 3 American adults</a>. </p>
<p>There are also many <a href="https://doi.org/10.1001/archpsyc.62.6.629">disparities in access to depression treatment</a>. Clinicians are less likely to recognize and treat depressive symptoms in <a href="https://doi.org/10.1176/appi.ps.201900407">certain groups</a>, including racial and ethnic minorities, men, older adults and people with language barriers. These disparities may be driven by poor patient-physician communication about mental health, cultural differences in discussing depressive symptoms, stigma around mental illness and limited available treatment options. </p>
<p>Limited time to discuss mental health symptoms in depth in primary care settings may also contribute to the depression treatment gap. As a <a href="https://profiles.ucsf.edu/maria.garcia">researcher and primary care physician</a> focused on improving access to mental health treatment, I have seen many patients struggle to have their depressive symptoms recognized by their clinicians and access quality care. Depression screening often only occurs when a clinician suspects the patient may have depression or when the patient specifically requests mental health care.</p>
<p>But making depression screening a routine practice could help reduce treatment disparities. In January 2016, the U.S. Preventive Services Task Force began <a href="https://doi.org/10.1001/jama.2015.18392">recommending depression screening for all adults</a>. In October 2022, given the mental health effects of the pandemic, it extended the recommendation to include screening all <a href="https://doi.org/10.1001/jama.2022.18187">adolescents age 12 and up</a> for depression and suicide risk during routine wellness checkups.</p>
<p>In our recent study, my team and I found that implementing <a href="https://doi.org/10.1001/jamanetworkopen.2022.27658">universal, routine depression screening</a> for adults in primary care is one way to make detection more equitable. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/qmJMNCGosWI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Depression and anxiety increased across the U.S. during the pandemic.</span></figcaption>
</figure>
<h2>Depression screening in one large health system</h2>
<p>The goal of our study was to evaluate whether the six primary care practices in the University of California, San Francisco health system had adopted routine depression screening for all their adult patients, and whether traditionally undertreated or untreated groups were being screened.</p>
<p>Medical assistants were asked to administer the screening test before patients saw their clinician. The clinician, after reviewing and discussing the results with the patient, could then arrange a follow-up appointment, prescribe a depression medication or submit a referral to a behavioral health specialist. </p>
<p>After two years, we analyzed data for 52,944 adult patients who had an appointment at one of the primary care clinics in that period. Screening rates were initially low – only 40.5% of patients were screened. Furthermore, men, older adults, racial and ethnic minorities, those with public health insurance, and those with language barriers were all less likely to be screened. For example, patients who spoke a Chinese language were almost half as likely to be screened as patients who spoke English.</p>
<p>However, with the UCSF health system’s coinciding focus on equity, screening rates increased to 88.8% by 2019. UCSF Health established a task force that met over the course of the project to discuss its progress, share best practices across primary care clinics and actively make adjustments to address screening disparities.</p>
<p><iframe id="eDJ42" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/eDJ42/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Overall, screening rates dramatically increased over those two years for all groups at risk of having their depression go unrecognized and untreated.</p>
<h2>Improving depression care for all patients</h2>
<p>Depression is a <a href="https://www.who.int/news-room/fact-sheets/detail/depression">leading cause of disability worldwide</a>. It can affect a person’s ability to manage other chronic conditions, and can lead to worsened disability and earlier death. </p>
<p>Our research found that increasing universal screening efforts can help reach groups that are less likely to be screened and treated for depression. We ensured that screening tools were available in other languages, clinical staff were periodically trained, and screening was integrated with routine clinical tasks. We also made sure that our efforts were aligned with the UCSF health system’s priorities, quality improvement efforts and reimbursement policies to reduce the burden of implementation and ensure sustainability.</p>
<p>While depression screening is necessary, it is not sufficient on its own to decrease care disparities for depression. Additional research is needed to see whether improved screening will lead to increased treatment and care engagement among at-risk groups.</p>
<p>Our team’s next steps are to evaluate whether a positive screen led to initiation of treatment for depression, and whether all patient groups were equally likely to engage in treatment. Our hope is that the lessons we learned from implementing routine depression screening in our primary care practices can encourage other health care systems around the country to do the same, and help better serve diverse patient populations.</p><img src="https://counter.theconversation.com/content/189509/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Garcia receives funding from the National Institute on Minority Health and Health Disparities.</span></em></p>Men, older adults, people with language barriers and racial and ethnic minorities are less likely to be screened for depression.Maria Garcia, Assistant Professor of Medicine, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907452022-09-27T20:21:39Z2022-09-27T20:21:39ZHow health-care leaders can foster psychologically safer workplaces<figure><img src="https://images.theconversation.com/files/486635/original/file-20220926-26-578e68.JPG?ixlib=rb-1.1.0&rect=134%2C143%2C2694%2C1895&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, abuse from patients and a pandemic have contributed to overwhelming burnout and job dissatisfaction among workers.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>Every day it seems the Canadian health-care staffing crisis worsens, with <a href="https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html">emergency room closures</a>, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">not enough family doctors</a> and <a href="https://www.wellesleyinstitute.com/wp-content/uploads/2020/09/Waiting-for-Long-Term-Care-in-the-GTA.pdf">long wait times to get into long-term care</a>. </p>
<p>At the core are health-care workers who are physically and mentally burnt out from the unsafe work environments they’ve been asked to work in for years, which were made remarkably worse during COVID-19. </p>
<p>Health-care leaders have a key role to play in developing psychologically safer workplaces to support the well-being of our health-care workers. Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, <a href="https://doi.org/10.1186/s12913-020-05084-x">abuse from patients</a>, and <a href="https://doi.org/10.3389/fpubh.2021.750529">the pandemic</a> have contributed to the overwhelming burnout and job dissatisfaction evident among workers.</p>
<h2>Physically and emotionally unsafe</h2>
<p>Even before the COVID-19 pandemic, Canadian health-care workers were experiencing <a href="https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf">burnout and depression</a>. The pandemic has worsened already poor working environments, exposing them not only to a life-threatening virus, but <a href="http://doi.org/10.1001/jama.2021.2701">mounting physical and verbal abuse</a>, <a href="https://www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf">increasing rates of burnout and depression</a>.</p>
<p>It is not surprising, then, that health-care workers are leaving the profession in greater numbers, <a href="https://www.cbc.ca/news/canada/nurses-canada-overtime-pandemic-burnout-1.6545963">further exacerbating the working conditions for the remaining health-care workers</a>. </p>
<figure class="align-center ">
<img alt="A paramedic in a face shield wearing a neon yellow jacket walks past patients on gurneys in a hospital corridor" src="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers, nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting burnout.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers (PSWs), nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting higher levels of stress. <a href="https://clri-ltc.ca/files/2021/02/PSW_Perspectives_FinalReport_Feb25_Accessible.pdf">PSWs working in long-term care report</a> physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</p>
<p>We know that <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Workforce_Psychological_Safety_in_the_Workplace_ENG.pdf">psychological health and safety in the workplace</a> is directly tied to productivity, retention, absenteeism, workplace conflict and the overall operational success of the workplace. Canadian health-care leaders, managers and supervisors are exceptionally placed to help health-care organizations build work environments where staff feel supported and safe. </p>
<figure class="align-right ">
<img alt="An outdoor sign reading 'Hiring PSWs - many shifts - benefits'" src="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">PSWs working in long-term care report physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span>
</figcaption>
</figure>
<p>Our research team was recently funded by the <a href="https://mentalhealthcommission.ca">Mental Health Commission of Canada</a> to examine the facilitators and barriers that health-care organizations face in creating safe work environments. We surveyed and interviewed <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">hundreds of health-care workers from across disciplines, workplaces and provinces</a>. Here’s what they told us: </p>
<ul>
<li><p>There is much focus placed on health-care workers building resiliency, but without giving them the time and space to do so. Organizations can help by protecting time off for workers. </p></li>
<li><p>Health-care workers have told us that long-term organizational resources such as wellness champions, ethicists and effective health benefits for all health-care workers (for example, benefits that cover counselling services) would help support their well-being. </p></li>
<li><p>Appropriate and transparent operational policies and procedures related to clinical care and/or human resources that pervade an entire organization help to develop a fair and safe working climate. Managers can further support their workers by ensuring those policies and procedures are consistently applied and followed.</p></li>
<li><p>Organizations should seek out and support effective, compassionate and authentic leaders. Developing health-care leaders who are skilled and rise to the job in their stressful environments is critical and should be cultivated and rewarded. Managers have also been through the wringer over the past several years and need to be supported by their organizations. </p></li>
<li><p>Fewer than 50 per cent of health-care workers in our study reported working in an ethical climate. For example, many health-care workers do not have access to the necessary supports to work through ethical dilemmas. This is a great place for health-care organizations to focus; cultivating an ethical work environment can demonstrate to its employees that they want to protect them from moral distress. </p></li>
<li><p>Health-care workers have told us that transparency and effective communications are critical and increase trust in their leaders. </p></li>
</ul>
<p>The future of our health system is dependent on recruiting and retaining passionate, hardworking and highly skilled health-care workers. Every health-care worker, in ever workplace, across every province needs an organization that values and prioritizes their psychological health and safety. For the full report please visit: <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">MHCC – Exploring Two Psychosocial Factors for Health-Care Workers</a>.</p><img src="https://counter.theconversation.com/content/190745/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>The future of our health system depends on recruiting and retaining passionate and highly skilled health-care workers. It’s essential to build work environments where they feel supported and safe.Angela Coderre-Ball, Assistant Professor (Adjunct), Family Medicine, Queen's University, OntarioColleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioDenis Chênevert, Professor and director of healthcare management hub, HEC MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1887122022-09-14T19:21:29Z2022-09-14T19:21:29ZHow improving COPD treatment in primary care could reduce demand on hospitals and emergency departments<figure><img src="https://images.theconversation.com/files/484673/original/file-20220914-19-lq6phg.jpg?ixlib=rb-1.1.0&rect=0%2C22%2C4715%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because of the difficulty in managing their care, patients with COPD have hospitalization rates 63 per cent higher than the general population, as well as 85 per cent more emergency department visits and 48 per cent more ambulatory care visits.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In Ontario, <a href="https://www.publichealthontario.ca/-/media/documents/c/2019/cdburden-report.pdf?sc_lang=en">nearly 900,000 people</a> live with chronic obstructive pulmonary disease (COPD). <a href="https://doi.org/10.1164/rccm.201211-2044OC">People with this condition account for 24 per cent of hospitalizations, 24 per cent of emergency department visits and 21 per cent of ambulatory care visits</a>. </p>
<p>Because of difficulty in managing care, patients with COPD have hospitalization rates that are <a href="https://doi.org/10.1164/rccm.201211-2044OC">63 per cent higher than the general population, as well as rates of emergency department and ambulatory care visits that are, respectively, 85 per cent and 48 per cent higher than the general population</a>, all of which contribute <a href="https://doi.org/10.1016/j.rmed.2007.10.010">significant financial costs</a> to Ontario’s health-care system. </p>
<p>Health-care sustainability has made headlines as emergency rooms around Ontario have closed due to <a href="https://www.cbc.ca/news/canada/toronto/ont-er-closures-1.6545119">staffing shortages, COVID-19 infections and burnout of frontline workers</a>. Ontario’s Health Minister Sylvia Jones has said that the province should <a href="https://toronto.citynews.ca/2022/08/11/ontario-health-minister-pushes-back-against-privatization/">embrace innovation</a> to help solve challenges within the health-care system. </p>
<p>Arguably, one of the most effective solutions would be to divert patients away from the emergency room and hospital in favour of more cost-effective primary care. Innovations in treatment of patients with COPD in primary care has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.</p>
<p>Fortunately, there is an existing program in primary care, called Best Care, that has been demonstrated to be <a href="https://doi.org/10.1186/s12962-022-00377-w">cost-effective</a>, <a href="https://doi.org/10.1186/s12913-022-07785-x">improve patient and provider experience</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce emergency department visits and hospitalizations</a>.</p>
<h2>The opportunity for Best Care</h2>
<p>Best Care is an innovative integrated disease management program (IDM) for managing high-risk, exacerbation-prone patients with COPD in a primary care setting. It was designed by a collaborative team of frontline health-care providers and administrators, supported by Ontario Health.</p>
<figure class="align-center ">
<img alt="A young woman behind a desk in a white coat with stethoscope watching an older woman use an inhaler" src="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.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">People in the Best Care program become active partners in their care, taking back control over their lives.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The <a href="https://doi.org/10.1038/s41533-019-0119-9">Best Care IDM program</a> involves <a href="https://www.argi.on.ca/copd-patient">embedding a certified respiratory educator</a>, who is also a case manager, within the primary care practice where the patient normally receives care. In collaboration with the patient’s primary care provider, the certified respiratory educator delivers or supports access to all 14 of <a href="https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-chronic-obstructive-pulmonary-disease-quality-standard-en.pdf">Ontario Health’s COPD quality standards</a>, including diagnosis, assessment, care planning, patient education, medication management and specialized respiratory care.</p>
<p>People in the Best Care program become active partners in their care, taking back control over their lives. The efficacy of Best Care has been empirically <a href="https://doi.org/10.1038/s41533-019-0119-9">demonstrated to improve patients’ quality of life and to help avoid emergency department visits</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce hospitalizations</a>. </p>
<p>Over the past three years, 7,000 Ontarians affected by severe COPD have benefited from the program. Three Ontario health regions implementing Best Care have shown dramatic reductions in COPD-related emergency department visits and hospitalizations.</p>
<h2>Evaluating cost-effectiveness</h2>
<p>Recently, with a team of health economists from the University of Ottawa, we <a href="https://doi.org/10.1186/s12962-022-00377-w">evaluated the cost-effectiveness</a> of the Best Care integrated disease management program for high-risk, exacerbation-prone patients in a primary care setting. In this research we used data from our earlier clinical study and the best available evidence to evaluate if investment in the Best Care program was cost-effective from the perspective of the Ontario health system. </p>
<p>Our results show that Best Care is not just cost-effective, but is dominant in comparison to standard care in Ontario. Best Care integrated disease management program was cost-effective in 85.3 per cent of our simulations.</p>
<p>When evaluating programs in terms of health economics, a program is <a href="https://doi.org/10.1016%2Fj.jacc.2008.09.018">dominant</a> when it improves patient outcomes and costs less than the alternative standard of care: in other words, better care at a lower cost. </p>
<figure class="align-center ">
<img alt="A man breathing into a white tube through his mouth, with a blue nose clip on his nose." src="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.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 of the ways COPD patients are assessed is spirometry, a test of lung function.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>With a modest up-front investment in primary care, the Best Care program is expected to dramatically reduce demand for acute health services. In fact, our modelling anticipates a 1.5-fold return on investment in the first year of implementation. Continued health system savings are expected for at least 10 years by reducing the number of urgent care and emergency room visits and the frequency of hospitalization.</p>
<p>We also ran several different scenarios to test the assumptions we made within our economic analysis. The results consistently demonstrated that Best Care integrated disease management program was cost-effective and dominant in comparison to the usual standard of care. When we assume that a patient’s quality of life should only improve with access to a certified respiratory educator/ case-manager (i.e., the patient’s quality of life should remain the same or increase, but not decrease), the probability that Best Care IDM is cost-effective increases to over 96 per cent. </p>
<h2>Sustainable health-care investment</h2>
<p>The <a href="https://www.ontario.ca/document/healthy-ontario-building-sustainable-health-care-system/chapter-2-vision-health-care-ontario">Ontario health system</a> seeks to invest in sustainable, innovative solutions that will maximize health-care capacity. This includes reducing avoidable hospitalizations and emergency department visits; improving patient, caregiver and provider experience; and enhancing patient outcomes while containing costs. </p>
<p><a href="https://doi.org/10.1038/s41533-019-0119-9">Prior peer-reviewed publications</a> and health system data have confirmed that the Best Care integrated disease management program improves patient outcomes as well as patient, caregiver and provider experience. Our robust health economic analysis confirms that Best Care is economically attractive compared to the current provincial care standard. </p>
<p>Best Care in COPD is a <a href="https://www.hqontario.ca/Portals/0/documents/health-quality/quality-matters-print-en.pdf">sustainable health-care investment</a> and delivers on all of the goals of the <a href="https://doi.org/10.1370%2Fafm.1713">quadruple aim approach to health care</a>: optimizing patient experience, improving health at the population level, reducing costs and supporting the well-being of health-care providers.</p>
<p><em>Madonna Ferrone, Director of Operations, Asthma Research Group Windsor-Essex County Inc., co-authored this article.</em></p><img src="https://counter.theconversation.com/content/188712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew D. Scarffe (he/him) received funding from the Asthma Research Group Windsor-Essex County Inc. in the form of a doctoral student stipend. He also receives funding from Mitacs Inc. through the Mitacs e-Accelerate scholarship. Andrew is a two time recipient of the Queen Elizabeth II Graduate Scholarship for Science and Technology and is a one time recipient of the Ontario Graduate Scholarship. He also receives funding from the Telfer School of Management and the University of Ottawa in the form of a graduate student scholarship and excellence (admission) scholarship. Publication of this article was not contingent on approval and/or censorship from any of the funding sources listed above.</span></em></p><p class="fine-print"><em><span>Dr. Licskai has received salary support from Western University as Professor of Health System Innovation and is the Medical Director of the Best Care in Primary Care program related to this work. Outside of the submitted work Dr. Licskai reports personal fees and / or research grants from AstraZeneca, GlaxoSmithKline, Novartis, Teva, and Sanofi Genzyme.</span></em></p><p class="fine-print"><em><span>Doug Coyle, Kednapa Thavorn, and Kevin Peter Brand 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>Innovation in primary care for COPD patients has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.Andrew Scarffe, PhD Candidate in Management (concentration in Health Systems), L’Université d’Ottawa/University of OttawaChristopher Licskai, Associate Professor of Medicine, Professor of Health System Innovation, Division of Respiratory Medicine, Western UniversityDoug Coyle, Professor, School of Epidemiology and Public Health, L’Université d’Ottawa/University of OttawaKednapa Thavorn, Senior scientist, L’Université d’Ottawa/University of OttawaKevin Peter Brand, Associate professor, Health Systems, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891992022-09-08T20:14:32Z2022-09-08T20:14:32ZWith family doctors heading for the exits, addressing the crisis in primary care is key to easing pressure on emergency rooms<figure><img src="https://images.theconversation.com/files/482397/original/file-20220901-14792-k5pnkl.JPG?ixlib=rb-1.1.0&rect=410%2C506%2C5418%2C3382&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span></figcaption></figure><p>The Ford government’s recently released plan to ease pressure on Ontario emergency rooms makes no mention of the <a href="https://ottawacitizen.com/opinion/abdulla-you-want-a-family-doctor-in-ontario-sorry-its-not-going-to-be-easy">mass exodus of physicians from family practice</a>. With that omission, the province’s <a href="https://files.ontario.ca/moh-plan-to-stay-open-en-2022-08-18.pdf">Plan to Stay Open</a> ignores the central role of family doctors in the health-care system, and sets itself up for failure.</p>
<p>A strong primary care system, identified as <a href="http://doi.org/10.1001/jama.1993.03500190088041">the cornerstone of health care</a>, keeps patients <a href="https://doi.org/10.1186/s12913-015-0705-7">away from emergency rooms</a> and plays a huge role in encouraging <a href="https://doi.org/10.9778/cmajo.20170007">self-management of illness and prevention of disease</a>.</p>
<h2>Critical role of primary care</h2>
<p>Focusing mainly on hospitals to fix the problem is akin to closing the barn door after the horses have fled. We must look upstream to primary care where about <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm">86 per cent of Canadians trust family doctors</a> to assist them in staying healthy. </p>
<p>In my ongoing research on integrated health-care systems — including <a href="https://health.gov.on.ca/en/pro/programs/connectedcare/oht/">Ontario Health Teams</a> and the capacity for family physicians to inform system change — I see a high degree of skepticism among family physicians about influencing system reform, since many have previously seen their input not heeded or not even sought. Time also limits their participation in health system research.</p>
<figure class="align-center ">
<img alt="A woman in a white coat is examining a little girl using a stethoscope, while another woman stands behind the girl." src="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.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">Ontario’s plan ignores the central role of family doctors in the health-care system, and sets itself up for failure.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily. At the same time, family physicians are fed up. No wonder that some are <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away because they “can’t take it anymore</a>.” </p>
<h2>Increasing challenges in family medicine</h2>
<p>Family physicians are dealing with significant burnout, ever-increasing workloads, unrealistic patient demands and <a href="https://www.cfp.ca/content/57/9/983.long">lack of respect from other specialties</a>. In addition to having a passion for providing continuous, comprehensive care, family physicians also need to acquire business acumen to manage overhead costs, performance management skills to hire, fire and coach office staff, and administrative prowess to deal with the mounds of paperwork that is done after the patient leaves (and is mostly non-billable). </p>
<p>Despite the value that most of us place on having a family doctor that we trust with our cradle-to-grave health issues, they are among the <a href="https://nationalpost.com/opinion/why-five-million-canadians-have-no-hope-of-getting-a-family-doctor">lowest paid and the least respected physicians, yet they have the most knowledge about the inefficiencies</a> in a health-care system that is coming apart more each day. </p>
<p>To make matters worse, supply is decreasing. This year’s residency applications through the <a href="https://www.carms.ca/the-match/">Canadian Resident Matching Service</a> (CaRMS) indicates that <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">the number of medical school graduates choosing family medicine as their top choice for training spots is declining steadily</a>. </p>
<p>This should be worrying for all of us as patients. More exploration into why family medicine is no longer seen as a worthy profession is sorely needed as more and more patients will be unable to access the continuous, comprehensive care they require. </p>
<h2>More Canadians without a family doctor</h2>
<p>News headlines continue to highlight that <a href="https://www.thestar.com/opinion/editorials/2022/07/30/an-unhealthy-shortage-of-family-doctor.html">more patients across the country are without a family doctor</a> and fewer doctors want to enter, or stay, in family practice. </p>
<p>In addition to diminished supply of new family doctors, many are heading for the exits earlier than anticipated. Family physicians are choosing to retire early, and in some cases <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away from large and long-standing practices</a> leaving more and more patients without a family physician and having no other option but to visit the emergency department for their health concerns. </p>
<figure class="align-center ">
<img alt="A stethoscope on a desk in the foreground, with a doctor out of focus sitting at the desk with his hands to his face" src="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.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">Family physicians are dealing with significant burnout and ever-increasing workloads.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Increasing the number of family physicians is important but retaining those that we already have should be viewed as absolutely critical. With the <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">average age of a family doctor in Canada at 49</a>, it’s not hard to predict that more retirements (planned or otherwise) will have a detrimental impact on the health of Canadians. </p>
<h2>Primary care challenges</h2>
<p>Primary care is not without its own challenges. For those that are lucky enough to have a family doctor, the time to see them varies, and <a href="https://healthydebate.ca/2015/11/topic/what-does-access-to-primary-care-really-mean/">access issues</a> are a common theme in patient complaints. Different physician offices use different appointment booking practices and scheduling rules, which can impact patient access ratings. </p>
<p>There are inequities between family physicians with solo practices in comparison to those who are attached to a family health team — health-care organizations that provide primary health care to communities and include various health professionals such as nurses, dietitians, social workers and others who share aspects of patient care with doctors. </p>
<p>Ontario has done better than most areas of Canada with the <a href="https://www.health.gov.on.ca/en/pro/programs/fht/">introduction of family health teams in 2005</a>, with team-based primary care reporting <a href="https://doi.org/10.1016/j.mayocp.2019.01.038">better outcomes for both patients and providers</a>. </p>
<p>But no new family health teams have been funded since 2012, which is a problem. Ontario Health Teams were introduced in 2019, and offer potential to influence what is currently a cadre of services (including primary care, hospitals, long-term care, home care, health support services) to function better as an integrated health system covering a geographic region. </p>
<p>Ontario Health Teams do not provide direct care, but are tasked with building a better system of care, working to break down silos between health-care providers and organizations to function better for patients. Primary care must be a major player in these. </p>
<p>Political will is required to invest in the entire health-care system and not ignore the fact that primary care represents a very large part of this system. We have a capacity crisis for certain — but cannot fix only one flat tire when all the tires are flat!</p><img src="https://counter.theconversation.com/content/189199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Grady 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>A strong primary care system keeps patients away from emergency departments and helps patients self-manage illnesses. But Ontario’s plan to ease pressure on emergency rooms ignores family medicine.Colleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1889022022-08-22T20:01:50Z2022-08-22T20:01:50ZGeneral practices are struggling. Here are 5 lessons from overseas to reform the funding system<figure><img src="https://images.theconversation.com/files/480248/original/file-20220822-53919-ccggoi.jpg?ixlib=rb-1.1.0&rect=53%2C161%2C5088%2C3261&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/KdWfhEwjcIE">Cesar Sampaio/Unsplash</a></span></figcaption></figure><p>New federal Health Minister Mark Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/address-to-the-australian-medical-association-national-conference-30-july-2022">says</a> primary care is “in worse shape than it’s been in the entire Medicare era” and has made it his top health priority. </p>
<p>Primary care is any first point of contact with the health system, such as a GP clinic, dentist, or community pharmacy, but the government is likely to focus on GP clinics. </p>
<p>A new <a href="https://www.health.gov.au/sites/default/files/documents/2022/07/strengthening-medicare-taskforce-communique-29-july-2022.pdf">taskforce</a> will advise the minister on how to spend <a href="https://anthonyalbanese.com.au/media-centre/labor-will-strengthen-medicare-butler-health">A$750 million</a> to improve access, chronic disease management, and affordability. The taskforce has until Christmas to come up with a plan, which is a big ask given where the system is now. </p>
<p>Taking lessons from what’s worked overseas, we’ve identified five key lessons about how Australia should reform general practice funding.</p>
<p>But first, let’s consider what’s gone wrong.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1557842578015686656"}"></div></p>
<h2>Primary care isn’t set up for the problems of today</h2>
<p><a href="https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity">Almost half</a> of Australians have a chronic disease, such as heart disease, diabetes, asthma or depression. More than half of Australians over 65 have two or more. Those proportions have been rising fast in recent decades. </p>
<p>To help patients manage these conditions, GPs <a href="https://www.annfammed.org/content/annalsfm/12/2/166.full.pdf">need</a> ongoing relationships with patients (known as continuity of care), and a team working with them by providing routine care, outreach, coaching, and advice. That lets GPs spend more of their time working with the most complex patients, resulting in <a href="https://www.annfammed.org/content/annalsfm/12/2/166.full.pdf">better care and outcomes</a>. </p>
<p>But the way GPs are funded – and the way the primary care system is managed – makes this nearly impossible. GPs tell us they <a href="https://insightplus.mja.com.au/2022/29/gps-at-top-of-medical-hierarchy-crying-out-for-respect/">aren’t respected</a>, are <a href="https://www.theage.com.au/national/i-m-totally-utterly-done-the-insider-take-on-our-growing-gp-crisis-20220628-p5axab.html?collection=p5b33m">stressed out</a>, and are set up to fail by a system that is fragmented, rigid, and unsupportive. </p>
<p>After decades of neglect, there are many problems to fix. Clinics often don’t have the right mix of staff, collaborating with specialists and hospitals is difficult, data systems are fragmented, and there are parts of Australia with poor access to care.</p>
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Read more:
<a href="https://theconversation.com/labors-health-package-wont-strengthen-medicare-unless-it-includes-these-3-things-183093">Labor's health package won't 'strengthen' Medicare unless it includes these 3 things</a>
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<p>One issue the taskforce must consider is how GP clinics are funded. While a simple boost to fees might be welcomed by practices, it can’t deliver the better access, quality, and affordability that Labor has promised. Australia’s approach has outlived it’s used-by date. </p>
<p>Here’s what Australia can learn from other countries that have transformed primary care funding: </p>
<h2>1: Blend payments to strike the right balance</h2>
<p>Australia is one of a small and shrinking list of countries that still mostly uses fee-for-service funding. There are payments to make care plans, and for working to <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/PIP-QI_Incentive_guidance">improve quality</a> measures (such as measuring risk factors or increasing immunisation rates), but the vast bulk still goes on individual GP consultations.</p>
<p>Shorter visits pay more, promoting a focus on speed not need – a poor fit for helping patients with complex needs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480286/original/file-20220822-67510-ppvw4w.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>
<figcaption>
<span class="caption">Funding per minute for MBS GP consultation items.</span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>Since the 1990s, many other countries have moved towards a “blended” funding model. After a patient enrols with with a particular doctor or clinic, GPs have ongoing responsibility for their patients and get flexible annual budgets for their care, along with a small fee for each visit. </p>
<p>This supports continuity of care and gives flexibility to provide different types of services, while keeping an incentive for GP consultations. It strikes a good balance between GP visits and other kinds of care, such as check-ins with a practice nurse, medication reviews from a practice pharmacist, or even support that goes beyond health care, such as help with housing or community services. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=560&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=560&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=560&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=704&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=704&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480257/original/file-20220822-64771-8sxjet.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=704&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">Primary care funding models around the world.</span>
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<h2>2: Adjust funding for health and social needs</h2>
<p>Australia’s core primary care funding system, the Medicare Benefits Schedule, does little to match funding with a patient’s needs. As shown above, it promotes short consultations, no matter how complex the patient’s health needs. It largely ignores disadvantage, even though people who are poor are likely to be <a href="https://www.aihw.gov.au/reports/australias-health/health-across-socioeconomic-groups">sicker</a>. </p>
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Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
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<p>New Zealand and Ontario (a province in Canada) introduced blended payments in the 1990s. However, they didn’t adjust annual patient budgets for clinical complexity or social need. Clinics received the same funding for treating someone who was healthy and wealthy as someone who was sick and poor. </p>
<p>It worked for practices in well-off areas, but not for those serving <a href="https://www.sciencedirect.com/science/article/pii/S0168851011002211">poorer communities</a>, resulting in reduced services. </p>
<p>The mismatch of care and need is a big problem in all health systems. Blended funding must be adjusted to level the playing field, otherwise it could make that mismatch even worse. </p>
<h2>3. Fund a multi-disciplinary team</h2>
<p>The patient budget described above gives clinics flexibility to fund different types of workers, such as mental health nurses, community health workers, or pharmacists. But experience overseas shows this isn’t enough to bring about best-practice multidisciplinary teams. </p>
<p>The United Kingdom and <a href="https://www.beehive.govt.nz/release/secure-future-new-zealanders%E2%80%99-health">New Zealand</a> also provide direct funding for different kinds of workers. In the UK, the full cost is covered for <a href="https://www.kingsfund.org.uk/sites/default/files/2022-02/Integrating%20additional%20roles%20in%20general%20practice%20report%28web%29.pdf">13 types of workers</a>, ranging from paramedics and podiatrists to “link workers”, a new role that coaches patients to achieve their health goals, and connects them to social support and community activities. </p>
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<img alt="Nurse takes a woman's blood pressure" src="https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480250/original/file-20220822-19099-1bnzwo.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">
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<span class="caption">The UK primary care system funds different types of health workers.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/pA0uoltkwao">Unsplash/Hush Naidoo Jade Photography</a></span>
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<h2>4: Step in when the market fails</h2>
<p>In parts of rural Australia, even the best blended funding model won’t attract GPs. In some cases, the demand from patients is too low or unpredictable to make it worthwhile running a stand-alone clinic.</p>
<p>In these cases of market failure, a different model is needed. Federal and state governments should work together to jointly employ salaried GPs and other primary care staff, giving them roles that might span the primary care clinic and a local hospital. </p>
<p>As the National Rural Health Alliance <a href="https://www.ruralhealth.org.au/news/advocating-racchos-model-health-care">proposed</a>, this could take the form of non-profit, community-controlled organisations, with similarities to <a href="https://www.naccho.org.au/acchos/">Aboriginal-controlled</a> clinics and community health providers. </p>
<h2>5: Recognise that change is hard and will take time</h2>
<p>A new funding model will require different workforce roles, reporting and data. Experience shows clinics must have strong support to help them change. </p>
<p>An <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/AD51EBE397452EF5CA2580F700164BAD/$File/HCH%20Interim%20eval%20report%202020%20Vol%201%20Summary%20report%20(Final.pdf)">evaluation</a> of the last major national attempt at primary care reform, Health Care Homes, recommended a change-management team within each practice with adequate training and protected time, as well as skilled external facilitators. In line with assessments <a href="https://www.kingsfund.org.uk/sites/default/files/2022-08/How%20to%20make%20change%20happen%20in%20general%20practice_Aug-2022.pdf">in the UK</a>, the evaluation also found that developing trust and peer support was crucial. </p>
<p>All this points to a staged roll-out over several years, with strong support within clinics, between clinics, and from <a href="https://www.health.gov.au/initiatives-and-programs/phn">Primary Health Networks</a>, the regional bodies responsible for improving the primary care system. </p>
<p>A long-term plan for change is more complex than a tweak to the Medicare Benefits Schedule. But it will be vital to give a sector under strain enough support to adapt to a funding system that’s better for workers and patients alike.</p>
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Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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<img src="https://counter.theconversation.com/content/188902/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon 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>How can we get better primary health care access, quality and affordability that Labor has promised? We need to learn from what’s worked and failed overseas.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1862782022-08-11T12:15:09Z2022-08-11T12:15:09ZHow primary care is poised to support reproductive health and abortion in the post-Roe era<figure><img src="https://images.theconversation.com/files/478117/original/file-20220808-17-4g635q.jpg?ixlib=rb-1.1.0&rect=69%2C53%2C5048%2C3283&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Primary care providers comprise nearly a third of the U.S. clinician workforce.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/new-jersey-jersey-city-doctor-with-patient-in-royalty-free-image/140193309?adppopup=true">Tetra Images/via Getty Images </a></span></figcaption></figure><p>Just over a month after the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">Supreme Court struck down 50 years of federal protection of abortion rights</a> in the U.S., at least <a href="https://www.guttmacher.org/article/2022/07/one-month-post-roe-least-43-abortion-clinics-across-11-states-have-stopped-offering">43 abortion clinics in 11 states</a> have stopped offering abortion services. In states where abortion remains legal, abortion clinics are experiencing <a href="https://www.nytimes.com/2022/07/23/upshot/abortion-interstate-travel-appointments.html">excessive wait times</a> due to the influx of out-of-state patients. </p>
<p>Wait times are only expected to grow as <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">more states restrict abortion with regulations</a> such as gestational age limits, waiting periods and requirements for in-person visits, unnecessary clinical tests and required parental consent for minors. Abortion bans and restrictions are associated with higher rates of complications and are <a href="https://www.colorado.edu/today/2021/09/08/study-banning-abortion-would-boost-maternal-mortality-double-digits">harmful to the health of women</a> because they delay necessary care. </p>
<p>Although primary care doctors and clinicians are not typically associated with the abortion debate, they are a critical, untapped resource to help offset the abortion care crisis. Primary care is a key access point for patients, especially for adolescent, low-income and rural women. </p>
<p>And because almost all Americans <a href="https://www.fiercehealthcare.com/practices/89-americans-value-relationship-primary-care-doctor">value their relationship</a> with their primary care provider, primary care has a responsibility to ensure patients <a href="https://doi.org/10.1007/s11606-020-06245-8">maintain personal bodily autonomy</a>, including deciding when and how many children to have. </p>
<p>In the post-Roe era, primary care providers can help their patients prevent unintended pregnancy and avoid delays in abortion care by providing comprehensive contraceptive and family planning services, knowing how to counsel and refer individuals seeking pregnancy termination and providing post-abortion care. Due to various state restrictions, providers should <a href="https://states.guttmacher.org/policies/">familiarize themselves with their specific state regulations</a> to determine what is permissible in their current practice environment.</p>
<p>We are practicing <a href="https://www.uwmedicine.org/bios/emily-godfrey">primary care</a> <a href="https://www.uwmedicine.org/bios/adelaide-hearst">physicians</a> who include comprehensive family planning as part of our practices. We have written extensively about the feasibility of <a href="https://doi.org/10.1007/s11606-021-06863-w">including full-spectrum birth control</a> and first-trimester <a href="https://doi.org/10.1016/j.pop.2018.07.010">abortion services</a> in primary care.</p>
<p>Primary care providers make up 30% of the <a href="https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook2021.pdf">entire U.S. clinician workforce</a>. They include family physicians, general internists, pediatricians and advanced practice clinicians such as nurse practitioners, midwives and physician assistants, who are often the only source of care in <a href="https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html">underserved and rural areas</a>. </p>
<h2>Primary care’s role in preventing abortion</h2>
<p>One of the top reasons why patients go to their primary care provider is for birth control. Primary care clinics that provide all-inclusive birth control services <a href="https://upstream.org/results/">reduce unintended pregnancy</a> rates in their communities, which can help alleviate the demand for abortion services. </p>
<p>Primary care providers can talk with their patients about becoming <a href="https://beforeandbeyond.org/toolkit/reproductive-life-plan-assessment">pregnant now or in the future</a>, using <a href="https://powertodecide.org/one-key-question">clinical tools</a> that help patients decide <a href="https://www.mypathtool.org/en/intro_mp">which birth control method</a> to use. </p>
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<a href="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic depiction of the variety of contraception and family planning methods." src="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.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>
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<span class="caption">Contraceptive methods range from IUDs and birth control pills to permanent sterilization.</span>
<span class="attribution"><span class="source">Centers for Disease Control and Prevention</span></span>
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<p>Nationally based <a href="https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm">birth control clinical guidelines</a> empower clinicians to prescribe even the most effective birth control methods, such as an implant or intrauterine device – IUD – to patients with serious and chronic medical conditions. Primary care can also help patients with emergency contraception, either in the form of a pill or IUD, within five days after unprotected sex. </p>
<p><a href="https://acrobat.adobe.com/link/track?uri=urn:aaid:scds:US:750761d8-2138-3bd7-bcda-af1b07cc8404">Emergency contraceptive pills</a> are considered safe and effective. They are high-dose birth control pills that work by <a href="https://www.webmd.com/sex/birth-control/faq-questions-emergency-contraception#">interfering with the process of ovulation</a>, and thus will not affect a pregnancy if already pregnant. Emergency contraception is a last chance to prevent unplanned pregnancy.</p>
<h2>Abortion pill prescription falls within primary care</h2>
<p><a href="https://theconversation.com/how-to-navigate-self-managed-abortion-issues-such-as-access-wait-times-and-complications-a-family-physician-explains-186186">Abortion with medications can be safely and effectively used</a> up to the 11th week of pregnancy, with low rates of complications. Of the approximately 1 million legal abortions provided each year in the U.S., 90% occur in the first trimester, or through the 12th week of pregnancy. Thus, it’s no surprise that <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than half</a> of abortions are now managed with <a href="https://doi.org/10.1007%2Fs11606-020-05836-9">medicines that can be prescribed by a primary care provider</a>. </p>
<p>The <a href="https://nap.nationalacademies.org/catalog/24950/the-safety-and-quality-of-abortion-care-in-the-united-states">National Academies of Sciences, Engineering and Medicine</a> have issued evidence-based guidelines reiterating that trained, licensed primary care clinicians can safely and effectively provide medication abortion. Patients who have received abortions from primary care providers report that they are <a href="https://pubmed.ncbi.nlm.nih.gov/25646981/#">satisfied with the experience</a>. Studies show that patients <a href="https://doi.org/10.1007/s10995-010-0722-4">prefer abortion services in primary care</a> <a href="https://doi.org/10.1016/j.contraception.2009.01.017">because of the privacy</a>, convenience and <a href="https://pubmed.ncbi.nlm.nih.gov/26950663/">continuity of care</a>. </p>
<h2>How abortion care can be integrated into telehealth</h2>
<p>Despite the fact that first-trimester abortion care <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.301119?">fits well within primary care medical services</a>, it has not been widely offered in this setting. This is <a href="https://doi.org/10.3122/jabfm.2022.03.210266">due to roadblocks</a>, including lack of provider training, federal and state legislation, institutional barriers and administrative resistance. </p>
<p>However, there are now new, <a href="https://doi.org/10.1016/j.contraception.2017.11.005">more simplified medication abortion protocols</a> that allow primary care to safely offer abortion care remotely with a <a href="https://doi.org/10.1001/jamainternmed.2022.0217">history screening tool</a> that doesn’t require unnecessary clinical laboratory and ultrasound testing. Primary care’s expansion of telehealth abortion services has the potential to significantly reduce delays in care. This could help reduce abortions at more advanced gestational ages and the complications that come with them. Our study from 2021 conducted among primary care physicians providing telemedicine abortion <a href="https://doi.org/10.1016/j.contraception.2021.04.026">found that more than 85% of patients</a> were less than seven weeks pregnant when they sought care. </p>
<h2>Post-abortion ‘primary’ care</h2>
<p>In states with restricted abortion access, it is inevitable that patients will seek abortions on their own. Given the current legal landscape, clinicians are often confused about how to treat patients with pregnancy complications, including miscarriage. The World Health Organization stresses that even in settings where abortion may be outlawed, it is incumbent for clinicians to provide <a href="https://srhr.org/abortioncare/chapter-3/post-abortion-3-5/">compassionate, nonjudgmental post-abortion care</a>. </p>
<p>Post-abortion care includes managing residual side effects or complications of abortion, as well as the provision of comprehensive birth control services without discrimination or coercion. Complications from abortion or miscarriage are rare. However, complications like retained pregnancy tissue in the uterus, bleeding or infection can occur, most of which can be managed by primary care providers in the clinical setting. </p>
<p>Primary care providers who don’t offer abortion care can still counsel patients about <a href="https://www.abortionfinder.org/">where to seek</a> reliable, high-quality abortion services. The U.S. Department of Health and Human Services provides information about <a href="https://reproductiverights.gov/">Americans’ rights to reproductive health care</a>. </p>
<p>The short-term implications of the Supreme Court decision remain uncertain as state legislators weigh public opinion among their constituents. </p>
<p>What remains certain in the post-Roe era, however, is that primary care continues to be among the most reliable resources in the U.S. for accurate information and safe reproductive health care services.</p><img src="https://counter.theconversation.com/content/186278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily M. Godfrey receives funding from Cystic Fibrosis Foundation and Society of Family Planning Research Fund. She is a Nexplanon Trainer for Organon</span></em></p><p class="fine-print"><em><span>Adelaide H. McClintock is the named institutional PI for a grant from the Society of Family Planning. This grant was officially awarded to Nina Tan. </span></em></p>Primary care doctors have long played an important role in providing birth control. Now, with the fall of Roe, they could help fill a critical need for comprehensive family planning services.Emily M. Godfrey, Associate Professor of Family Medicine and Obstetrics & Gynecology, School of Medicine, University of WashingtonAdelaide H. McClintock, Professor of Internal Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1830932022-05-17T03:55:43Z2022-05-17T03:55:43ZLabor’s health package won’t ‘strengthen’ Medicare unless it includes these 3 things<p>“Strengthening Medicare” is one of Labor’s key election platforms. On Saturday, one week from the election, the opposition finally <a href="https://anthonyalbanese.com.au/media-centre/labor-will-strengthen-medicare-butler-health">outlined its commitment</a> to prop up the ailing primary care system, with a A$970m funding package.</p>
<p>The promise of additional funding for primary care is welcome. More money is badly needed, but Labor’s plans have no detail on how this will improve health outcomes and equity of access.</p>
<p>In order to ignite the structural health care reform we so desperately need, Labor needs to focus on three key areas: GP numbers, free access to GPs and better access to specialists.</p>
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<a href="https://theconversation.com/how-do-the-major-parties-rate-on-medicare-we-asked-5-experts-182230">How do the major parties rate on Medicare? We asked 5 experts</a>
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<h2>Remind me, what is primary care?</h2>
<p>Primary care is a person’s first point of contact with the health system. This is usually in general practice, with GPs and practice nurses, and also includes some care provided in community health centres and Aboriginal community-controlled health services. </p>
<p>The current Liberal government published its <a href="https://www.health.gov.au/resources/publications/australias-primary-health-care-10-year-plan-2022-2032">Primary Care ten year plan</a> in 2022 after a <a href="https://consultations.health.gov.au/primary-care-mental-health-division/draft-primary-health-care-10-year-plan/">consultation</a> period starting in 2019. It included technological improvements to boost quality, voluntary patient registration for the elderly (to sign up with a GP clinic which will support their long-term, chronic diseases), and support for integrated care, allowing people to move more easily from hospital to primary care, and other parts of the health system. </p>
<p>But as the Australian Medical Association (AMA) has highlighted throughout the campaign, this plan remains unfunded. </p>
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<h2>What does Labor’s plan include?</h2>
<p><a href="https://anthonyalbanese.com.au/media-centre/labor-will-strengthen-medicare-butler-health">Labor’s plan</a> promises new funding of A$950 million. The centrepiece is a new, so-called Strengthening Medicare Fund of A$750 million that aims to improve access to GPs – though it doesn’t say how. There is little detail on how this fund will be used.</p>
<p>The “how” will be decided by a so-called Strengthening Medicare Taskforce, chaired by the new health minister, plus many of the same people who designed the Liberals’ plan. It’s therefore unclear how different this would end up being from the Coalition’s plan. </p>
<p>Labor’s plan also includes A$25,000 or A$50,000 grants to improve practice infrastructure including IT, “upskilling” staff, and new equipment including infection control. </p>
<p>Direct subsidies to support the costs of running a practice is important, though by itself does not guarantee more patients can find a bulk billing GP. Nor does it guarantee the <a href="https://theconversation.com/rising-out-of-pocket-health-costs-are-a-worry-but-the-major-parties-have-barely-mentioned-it-181595">rising health care costs</a> will slow down.</p>
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<h2>Three problems that need to be fixed</h2>
<p>The taskforce will take time to deliberate. But here are some ideas to begin with. </p>
<p><strong>1) Address the GP shortage</strong></p>
<p>There remains a chronic shortage of GPs, with many GP training places <a href="https://www.aph.gov.au/DocumentStore.ashx?id=379fba97-8d67-4831-9f1c-cc3a8c6a4eb7&subId=716543">remaining unfilled</a> and with a much <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">higher growth</a> in the number of specialists compared to GPs.</p>
<p><a href="https://minerva-access.unimelb.edu.au/items/4495ceea-9018-50ea-b9c1-6ee09791a1b6">Our research</a> has shown three things can persuade junior doctors to choose general practice as a career: money, more procedural work (such as helping deliver babies or removing skin lesions) and more opportunities for research and academic work. </p>
<p>There are no policies in any parties’ plans that address these. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>More money needs to be used carefully and needs to reduce the large <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">gap between GPs’ and specialists’ incomes</a> if more junior doctors are to be attracted to this specialty. </p>
<p><a href="https://minerva-access.unimelb.edu.au/items/bc6d10b3-938b-56c0-bc11-21524d1233c3">Procedural work for GPs</a> exists in rural areas but is more tricky in cities, but many city GPs have specific special interests in undertaking procedures that should be better supported. </p>
<p>Primary care research and basic data collection remains a <a href="https://www.mdpi.com/1660-4601/19/4/1912">gaping hole</a> in need of additional funding. </p>
<p><strong>2) Increase free access to GPs</strong></p>
<p>The key issue for many patients is accessing free GP services, with many people <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">avoiding GP visits</a> because they have to pay. </p>
<p>Again, nothing in either party’s plan will directly reduce out-of-pocket costs. </p>
<p>The solution requires new, innovative funding models for primary care, especially in low socioeconomic and rural areas. This could include federal government funding to expand community health centres, which are run by states.</p>
<p>There has never been a specific policy focus in Medicare for low socioeconomic areas. </p>
<figure class="align-center ">
<img alt="Main in a respirator waits for this GP appointment." src="https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.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">
<figcaption>
<span class="caption">Cost is a major issue for some people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/prague-czechia-patient-kn95-respirator-waiting-1933933733">Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>3) Improve access to specialists</strong></p>
<p>Labor’s plans are about strengthening Medicare, yet the largest part of spending on Medicare services is for services provided by specialists. Of the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/32CC6EB4BCC0BB1CCA257BF0001FEB92/$File/Annual%20Medicare%20Statistics%20-%20State%20-%202009-10%20onwards.xlsx">total spending on Medicare benefits</a> of A$27.5 billion in 2020-21, 32% (A$8.8 billion) was spent on GPs, while 54% (A$14.2 billion) was spent on other specialists. </p>
<p>However, the Labor and Coalition plans completely ignore the continuing problems of <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0016/2800141/ANZ-MI-Health-Sector-Report-Specialists-2018.pdf">access to specialists</a>. </p>
<p>Rich people have <a href="https://www.sciencedirect.com/science/article/abs/pii/S0168851020302244">better access</a> to specialists, including for <a href="https://www.sciencedirect.com/science/article/pii/S0277953618302041">child health services</a>. You either wait up to a year for a public hospital appointment or pay sometimes exorbitant out-of-pocket costs. This contributes to significant inequalities in health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-surgery-waitlists-in-crisis-and-a-workforce-close-to-collapse-why-havent-we-had-more-campaign-promises-about-health-182327">With surgery waitlists in crisis and a workforce close to collapse, why haven’t we had more campaign promises about health?</a>
</strong>
</em>
</p>
<hr>
<h2>What next for Medicare?</h2>
<p>It’s easy to point out what’s wrong with the Australian health system, and much harder to think of solutions, especially where significant structural change is actively discouraged by some in the sector. </p>
<p>We need primary care that is guaranteed to be free and accessible for a significant part of the population in the bottom half of the income distribution. </p>
<p>More money is good only if it can address these issues to properly strengthen Medicare and primary care.</p><img src="https://counter.theconversation.com/content/183093/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives some funding from the Medibank Beter Health Foundation.</span></em></p>Labor’s election pledge for Medicare includes some additional funding, but to strengthen the system, it needs to improve people’s access to doctors.Anthony Scott, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1698182021-10-27T15:00:52Z2021-10-27T15:00:52ZThe doctor won’t see you now: Why access to care is in critical condition<figure><img src="https://images.theconversation.com/files/427796/original/file-20211021-16-l27u13.jpg?ixlib=rb-1.1.0&rect=44%2C141%2C4992%2C3078&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In addition to patient care, many doctors also have heavy administrative burdens, including insurance company requests and government forms that advocate for their patients' needs, as well as all the challenges of running an office.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-doctor-won-t-see-you-now--why-access-to-care-is-in-critical-condition" width="100%" height="400"></iframe>
<p>If you woke up tomorrow with a sore throat, how quickly could your doctor see you? What if your child developed a rash? Or are you one of the <a href="https://globalnews.ca/news/7745248/federal-budget-canadian-medical-association-family-doctor-access/">estimated five million</a> Canadians who don’t have a family doctor and rely on a patchwork of walk-in clinics and emergency rooms? </p>
<p>As a family doctor, I know that this lack of access matters. A lot. A large body of research has clearly demonstrated that <a href="https://www.fyam.dk/files/23/artikel_3._starfield.pdf">your health is better when you have a family doctor</a> and that this care is also <a href="https://doi.org/10.1111/j.1468-0009.2005.00409.x">safer and less costly to the system</a>. </p>
<p>Yet <a href="https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly">Canada’s health-care system continues to lag</a>, and our access to care ranks ninth out of 11 high-income Organization for Economic Co-operation and Development (OECD) countries. Fifty-nine per cent of Canadians say their doctor will return their call the same day; <a href="https://www.theglobeandmail.com/life/health-and-fitness/health/how-quickly-can-you-see-a-doctor-study-shows-canada-lags-behind-other-nations-on-timelyaccess/article34043606/">only 43 per cent can actually see their doctor in that time</a>. </p>
<p>With Canada spending <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/201127/dq201127a-eng.htm">$186.5 billion</a> a year on health, why are there barriers to timely care?</p>
<h2>Primary care</h2>
<p>Canada has the <a href="https://data.oecd.org/healthres/doctors.htm">second-lowest number of doctors </a> per capita of the 11 high-income OECD countries. In 2021, there were over <a href="https://www.carms.ca/pdfs/2021-R-1-data-snapshot.pdf">1,500 new family medicine training positions</a> across Canada. Some of these graduates will go on to focused practices in emergency medicine, palliative care or hospitalist medicine (general practice physicians who treat patients in hospital). These are needed and important services, but ones not properly accounted for in health human resources. </p>
<p>Those who want to work in primary care are faced with some financial realities. With medical student debt <a href="http://afmc.ca/web/sites/default/files/nationalreports/2020_AFMC_GQ_National_EN.pdf">often over $100,000</a>, it’s no wonder that new graduates avoid further financial hardship. In-person and virtual walk-in clinics provide opportunities to work without overhead expenses. While these stop-gap measures are helpful to patients in the short-term, they reflect a model that rewards high-volume and episodic care; the doctor on the other end of the screen may even be in a different province. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Justin Trudeau in profile wearing a face mask in the foreground, a couple with a child in the background" src="https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=594&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=594&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427702/original/file-20211021-17-14rn2w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=594&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Liberal leader Justin Trudeau meets with a family and physicians to discuss the difficulties in finding a family doctor at a campaign stop in during the 2021 federal election campaign.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span>
</figcaption>
</figure>
<p><a href="https://hbr.org/2016/12/why-the-best-hospitals-are-managed-by-doctors">Health settings led by doctors generally perform better</a>, but few doctors receive business training. Upon graduation we suddenly find ourselves as small business owners hiring and managing staff, negotiating leases and performing tasks that cause stress and take us away from patients.</p>
<p>And patient care also carries heavy administrative burdens. Dealing with pharmacy refill faxes, insurance company requests and government forms that advocate for our patients to have safe housing, food security and needed treatments requires hours of time every week. And while electronic medical records (EMRs) promised efficient paperless offices, it is estimated that <a href="https://www.forbes.com/sites/brucelee/2020/01/13/electronic-health-records-here-is-how-much-time-doctors-are-spending-with-them/?sh=638a9b805172">doctors spend one-third of their time working on EMRs</a>. <a href="https://www.doctorsofbc.ca/sites/default/files/physician_burdens_policy_statement.pdf">These burdens are a major cause of burnout</a> that in turn further shrink the physician workforce.</p>
<h2>Let doctors be doctors</h2>
<p>Despite these challenges, there are solutions.</p>
<p>First, let doctors be doctors. Pilots don’t serve coffee on planes. Few dentists scale and polish teeth. We need to <a href="https://www.doctorsofbc.ca/news/team-based-approach-care-benefits-patients-and-providers">create and fund teams</a> so that doctors and other health-care professionals like nurses, psychologists, dietitians and social workers come together and all work within our scope.</p>
<p><a href="https://www.medicalscribesofcanada.ca/">Medical scribes</a> could help with EMR data entry. Business supports or private-public partnerships in clinics could allow doctors to contribute to the efficiency of where we work while allowing those with the interest, training and experience to handle the business aspects of running a practice. Good governance and oversight where patients, doctors, government and administrators all sit at the same table can ensure public accountability, transparency and prioritization of patient care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="cropped image of a doctor using a smartphone" src="https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427712/original/file-20211021-17-1mb3e8w.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">Widespread adoption of virtual care has been one silver lining of the pandemic.</span>
<span class="attribution"><span class="source">(Unsplash/National Cancer Institute)</span></span>
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</figure>
<p>One silver lining of the pandemic has been the <a href="https://doi.org/10.9778/cmajo.20200311">widespread adoption of virtual care</a>. While it does not always replace in-person visits, it is another tool we can use to give the right care at the right time in the right place. We need to ensure that it is used to improve access to doctors in the context of ongoing longitudinal relationships.</p>
<p>Similarly, we need to align payment models to the care we want given. We need to reward doctors who take on the responsibility of long-term patient relationships, especially those who care for people with <a href="https://gpscbc.ca/what-we-do/incentives">the greatest vulnerabilities</a> such as patients with multiple chronic conditions. </p>
<h2>Safe work environments</h2>
<p>Lastly, we need to stop endangering doctors. The horrific murder of <a href="https://www.macleans.ca/society/the-gruesome-killing-of-an-alberta-gp-puts-a-spotlight-on-physician-abuse/">Dr. Walter Reynolds</a>, a family doctor who was attacked in his Red Deer, Alta., walk-in clinic in August 2020, is a tragic reminder of the increasing risks doctors face. </p>
<p>We need <a href="https://theprovince.com/opinion/op-ed/opinion-healthcare-workers-need-safe-places-to-work">safe places to work</a> retrofitted with panic buttons, electronic door locks and examination rooms that do not place patients between medical staff and exit doors. The pandemic and anti-vaccine attacks have caused doctors tremendous <a href="https://globalnews.ca/news/8180250/mental-health-frontline-workers/">moral injury</a>; we too need access to health services, especially as many doctors do not have a doctor themselves.</p>
<p>The pandemic has exposed many cracks in our already-stressed health-care system. Repeated political promises to provide <a href="https://www.thestar.com/opinion/contributors/2021/08/15/build-back-better-every-canadian-should-have-a-family-doctor.html">a family doctor for every Canadian</a> have fallen short of the goal, and <a href="https://www.canhealth.com/2021/10/13/survey-access-to-healthcare-top-priority-for-ontarians/">improving access remains a top concern</a>. </p>
<p>Providing doctors with the supports we need will allow us to increase access for patients and continue being there for you when you need us most.</p><img src="https://counter.theconversation.com/content/169818/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric Cadesky 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>Less than half of Canadians can see their doctor same-day, and millions don’t even have a family doctor. Improving access to care means providing doctors with the support they need to focus on patients.Eric Cadesky, Clinical Associate Professor, Faculty of Medicine, University of British ColumbiaLicensed 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>
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</em>
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<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">
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<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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<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>
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<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>
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</p>
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<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>
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<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>
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<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>
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<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>
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<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>
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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>
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<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.