Grattan primary care report right, says GP

A LEADING general practitioner has agreed with the findings of the latest Grattan Institute report into chronic disease in primary health care, but says if GPs and primary health networks (PHNs) had access to the same data they would be able to help their patients to better outcomes.

The Grattan report – Chronic failure in primary care – was released last week to criticism from both the Royal Australian College of GPs and the Australian Medical Association.

It concluded that: “Our primary care system is not working anywhere near as well as it should because the way we pay for and organise services goes against what we know works”.

“At best our primary care system provides only half the recommended care for many chronic conditions. Only a quarter of the nearly one million Australians diagnosed with type 2 diabetes get the monitoring and treatment recommended for their condition.

“The role of GPs is vital, but the focus must move away from fee-for-service payments for one-off visits. A broader payment for integrated treatment would help to focus care on patients and long-term outcomes ... The evidence shows that a consistent, coordinated approach to specific diseases helps primary care more effectively prevent and manage chronic conditions,” the authors wrote.

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Dr Linda Mann, a GP in the inner west of Sydney and a long-time advocate for health care reform, said the authors of the Grattan report, Stephen Duckett, Hal Swerissen and Jo Wright, were “very, very right”.

“GPs can’t do any better because of the way Medicare functions,” Dr Mann told MJA InSight.

“What are we supposed to do, when we are denied access to the resources that could help [our patients with chronic diseases]?”

Dr Mann cited the way Medicare deals with mental health care programs such as Access to Allied Psychological Services (ATAPS) as a case in point.

“The federal government has told us that [tools] like ATAPS are only to be used for short-term mental health problems – problems that are perceived as quickly treatable,” she said. “We’re not allowed to use those services for people with long-term problems.”

The availability of data and feedback was also an issue for GPs and PHNs, she said, pointing out that data available to the Grattan Institute via paid-for patient management systems like MedicalDirector, were not necessarily available to doctors on the frontline of care.

“We need data,” Dr Mann said. “We are currently denied data. We want to know who is doing things sensibly and who is doing them badly so we can help them.

“Immunisation programs are an example of how data-sharing works well – the data on who is being immunised, for what, and when, is gathered practice by practice so that the PHN can help those practices that are not doing well.

“Why can’t we do this for other [procedures]? Privacy [regulations].

“The PHN cannot determine who’s doing what. If they had the data we could do appropriate things [to improve care of chronic disease patients].”

Developing care plans for patients was one area where Dr Mann saw a need for reform. The ideal use of a care plan was to allow a patient with chronic diseases to access allied health services – to act as a “gatekeep”, she said.

“But they are also developed so the practice can make money, frankly,” she said. “Bulk-billing practices are bereft of cash and they will do anything, within the Medicare system, to try to [generate income].”

That included developing care plans for patients who were not necessarily in need of one, with perhaps 1 in 15 reflecting a genuine need, Dr Mann said.

“If the audits worked, the practices would be given feedback – but that’s a conversation neither the RACGP nor the AMA are willing to have, it seems.”

The chair of the RACGP’s Expert Committee on Quality Care, Dr Evan Ackermann, said he “fundamentally disagreed” with the Grattan Institute’s conclusion that primary care was “failing with chronic disease”.

“What information we do have suggests that we’re heading in the right direction.”

Dr Ackermann did agree that there needed to be a different way to manage chronic disease.

“Chronic diseases are complex, particularly among aged patients with multiple comorbidities,” he said. “GPs only have one tool to manage it.

“What is missing is a way to manage complex scenarios, and it’s true that we don’t do that well.”

Professor Stephen Duckett, co-author of the report and Director of the Grattan Institute’s Health Program, told MJA InSight that he was “unsurprised” by the initially negative responses to the report from the RACGP and the AMA.

“There are a number of ways of responding – they could deny the evidence, they could bury their heads in the sand, they could say they didn’t like the way we phrased it but yes, or they could say ‘yes you’re right, let’s get on with it’.

“I’ve seen it all.”