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THE corporatisation of after-hours GP locum services may be creating a need in search of profit rather than meeting a previously unmet need, risking the quality of care being given to vulnerable older patients, says an Australian expert.
Professor Kirsty Douglas, professor of general practice at the Australian National University, told MJA InSight that significant shifts in Medicare claims for after-hours services, as well as changes in advertising regulations that made it possible for medical deputising services to advertise directly to the public, had complicated an already byzantine model of aged care.
“Here in the ACT, for example, there has been a longstanding alliance between a group of practices which has provided after-hours services, but in the past 2 years one of the national players in medical deputising has moved into the area as well, and is advertising heavily regarding bulk-billing 100% of their services,” Professor Douglas said.
“Since then, there has been a 10-fold increase in claims for urgent care after hours on the MBS.
“We need to understand whether we are meeting previously unmet needs, or are we creating demand in the search for profit? I have a concern that that may be happening – we’re creating demand, not meeting need.
“The question is, with a number of significant players who are driving the profit as far as it can go, are we losing the quality of care because of that?”
Professor Douglas was commenting on research published this week in the MJA by a team from Monash University, Gippsland Primary Health Network and POLAR Melbourne East GP Network.
Using administrative data routinely collected by the Melbourne Medical Deputising Service for the 5-year period from 1 January 2008 to 31 December 2012, the researchers analysed the data for older people (≥ 70 years old) residing in greater Melbourne and surrounding areas. Of the 357 112 bookings logged for older patients during 2008–2012, 81% were for patients in residential aged care facilities (RACF), a “disproportionate use of the service” compared with that by older people dwelling in the community.
“During 2008–2012, the booking rate for RACFs increased from 121 to 168 per 1000 people aged 70 years or more, a 39% increase; the booking rate for people not living in RACFs increased from 33 to 40 per 1000 people aged 70 years or more, a 21% increase,” the authors wrote.
“The higher booking rate for patients in RACFs than for those in private dwellings … probably reflects their greater frailty and poorer health, but may also reflect the lower number of GPs providing care to people in RACFs.
“Conversely, lack of knowledge about alternative after-hour primary care services among people not living in RACFs may have contributed to their lower booking rates.
“The large increases in the relative booking rate for both RACF and non-RACF residents (40% and 20% respectively) indicate that the deputising service is responding to a growing and appropriate need, as only a small proportion of bookings resulted in an urgent transfer to hospital.”
Professor Dimity Pond, professor of general practice at the University of Newcastle, wrote in an accompanying editorial in the MJA that the number of GPs using a deputising service had increased from 38% in 2005–06 to 48% in 2014–15, and that the reasons for that increase were “complex and require further examination”.
“They include the increase in the size of the population of older people, and government initiatives that encourage GPs to provide after-hours services, either directly or through deputising services,” Professor Pond wrote.
“The annual collection of data on 100 000 GP consultations in Australia known as BEACH has revealed a GP workforce that is ‘more feminised, older … and worked fewer hours per week’. Other factors might include the dangers of after-hours visiting, stretched GP workforces, and a trend among GPs toward a better work–life balance.”
Professor Douglas said that the MJA research provoked more nuanced questions that needed to be investigated.
“For example, what models of staffing in RACFs have an impact on the numbers of call-outs for deputising services?
“If an RACF has a registered nurse on duty overnight, are they less likely to call a doctor in, than another which has a relatively less skilled nurse, who is working off a list of criteria? A registered nurse will have the skills and experience to make a judgement [case by case], while the less qualified nurse is probably more likely to call in a doctor,” Professor Douglas said.
Professor Pond said that locum service doctors were “not equipped to care for complex older patients in an optimal manner”.
“They do not necessarily have a postgraduate qualification, they do not know the patient, and they are not supported by staff who are well trained and familiar with the medical conditions of each patient,” she wrote. “We need to examine the reasons for calls to medical deputising services, and whether they are associated with excess morbidity and mortality.”
Professor Chris Pearce, co-author of the MJA research and director of research at POLAR Melbourne East GP Network, told MJA InSight that there were four things that would improve after-hours care for older patients.
“First, we need to embrace the shared electronic health record environment to enable better availability of information,” he said.
“We’re never going back to the days of 3 am phone calls to our own GP for a house call. We’re always going to rely on deputising services rather than ambulances, so sharing patient information is vital.
“Secondly, we need better incentives for GPs to engage in aged care in their general day-to-day practice.
“Thirdly, RACFs need better, integrated protocols for after-hours care, and fourth, we need to broaden the scope of advanced care planning. It’s not just about end-of-life matters, but should also be about our wishes about our care in general.”
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As someone who worked in RAC facilities as a nurse’s aid on the way through med school and then as a consultant in acute care hospitals (including general medicine for many years) – I would like to see an advanced care directive made a obligatory part of the ACAT process.
In my experience, (~30yrs in above roles) very few people want to be “saved” to return to RAC facilities esp HLC, yet residents are regularly sent to EDs where they are “cared” for by Drs in an “acute care” frame of mind who have never met them before and have no idea about their wishes…. Surely with a little bit of common sense and good record keeping we can allow more people to be cared for without invasive, intensive and futile “care” in EDs and acute care settings?
this is a waste of ED time, an assault to many people who would not choose this for themselves and makes no sense… written after another weekend on-call where a 91 yo was treated to death, after coming in from HLC in a RAC setting – when she could have been allowed to die in a familiar setting if only there had been a good discussion before the ambulance ride…..
Some residents in nursing homes are cared for long term by a series of visits by locum doctors after hours as there is no GP available to visit them. These locums often perform routine tasks after hours such as rewriting medication charts – which are then not reviewed or modified to reflect the changing needs of that resident. This hardly makes for good continuity of care or good quality care.
Some families insist on continuing with a long standing GP who may be several suburbs away and so cannot visit. Then when the resident is too unwell to travel to the clinic, locums are used after hours to provide adhoc care which may be inappropriate.
Thus the current system of medical care is not working well. In addition the residents moving in to aged care facilities are now more frail and closer to the end of their life and thus have higher needs. At the same time cost cutting, especially in the for-profit sector, is reducing the expertise of the staff at the facilities as more low skilled staff replace nurses.
A better model may be having a GP practice co-located with aged care facilities. In addition remuneration which reflects the complex nature of the care is required.
What bugs me is when I get a call through the day and I have to visit a nursing home on the way home after surgery – usually about 7pm. I have the usual issues of having to get the door unlocked and then finding the senior nurse – often not a RN. But the real killer for me is the rebate the patient gets when I attend is less than half the rebate the patient gets if a junior inexperienced doctor from an out of hours service attends at exactly the same time.
it’s too easy these days just to send all the nursing home patients to
Emergency departments by ambulance,
Everyone bitches about AMDS doctors. Fine, you get a PIP incentive for arranging after Hours care for your patients. Well get out of your bed and look after your patients! I feel appreciated by patients and nursing home staff for covering out of Hours medicine. My patients greatest complaint is ” I can’t get an appointment with my doctor and we cannot get the patients doctor to review them in the nursing home. Before you dismantle AMDS be careful what you wish for!