Patients want health, not necessarily treatment

This is the speech delivered by Dr Bastian Seidel, president of the Royal Australian College of General Practitioners, to the National Press Club on Monday 20 March, 2017. It is published here in full.

I’m very pleased and proud open the RACGP’s Canberra office here at the National Press Club today. This is an important milestone for our organisation and our members and it’s fabulous to see such a great turnout today. Thank you all for attending and making the time in your busy schedule.

The RACGP has come a long way since its foundation almost 60 years ago. As an academic medical college we set the standards for the medical specialty of general practice. We write the curriculum, provide education and hold postgraduate exams ultimately leading to the Fellowship of the College. And clearly Fellowship of the RACGP is the premier qualification of excellence and distinction within the medical specialty of general practice. Its national and international recognition is second to none, and rightly our Fellows are using their post-nominals with pride and dignity. The RACGP is now the largest medical organisation in Australia. We have over 35 000 active members in all states and territories. Over 80% of all Australian GPs call the RACGP their professional home.

Achieving recognition as medical specialists in our own right has been an uphill battle for GPs for decades. We only achieved vocational recognition as specialists in the 1990s. However, for many, we are still seen as #JustaGP, a term that symbolises the academic and professional discrimination our members are still subjected too. Old habits die hard.

Look at our esteemed universities. We only have a few full Professors of General Practice nationwide. The implications are significant: poor representation of general practice in the undergraduate teaching of medical students, for example. Students are lucky to spend a few weeks of their 5-year training in our specialty in the community. The vast majority of teaching takes place in the hospital setting.

Consider medical research: less than 2% of NHMRC research funding is awarded to research conducted in general practice – 98% of research funding will end up in tertiary care centres, hospitals and metropolitan institutions.

Shouldn’t we ask ourselves whether the evidence derived in those high-tech silos applies to care in the low-tech general practice setting? Shouldn’t we ask whether efficacy demonstrated in controlled hospital environments translates to effectiveness in the complex real world of comorbidities, social, economic and cultural contexts of general practice? It is self-evident that the answer to both questions has to be a firm no. That’s why 85% of all medical research is wasted. This is not what our patients expect, this is not what the taxpayer expects either.

Although major gains were achieved funding hospital-based treatments and hospital-based research in the 20th century, the 21st century shows us a clear example of the law of diminishing returns. As a nation, we can’t continue on those old trodden paths. They lead to nowhere. Let’s pause and reflect, because we need to consider nothing else but a shift of the norm. The norm should be that 21st century health care is delivered in the community, not in hospitals, and subsequently the focus needs to shift from offering expensive treatments of disease in institutions to effective strategies to maintain health in the community. I’d argue that patients want health, not necessarily treatment. Isn’t it time that our health system was reflecting that?

Hospitals and funding

Australia’s health system is hospital-centric. And we should be proud of the advances we’ve made in the tertiary care sector, in particular in the last century. Hospitals in Australia are of the highest standard, whether they are public or privately run institutions.

However, hospitals are extraordinarily expensive to run. The total recurrent health expenditure for public hospital services alone is over $45 billion per year — $19 billion are contributed by the Federal Government, the remainder is contributed by the states and privately. The cost of private hospitals is over $12 billion, that vast majority covered by private health insurance which, again, is subsidised with over $6.5 billion dollars per year by the taxpayer.

Compare that with the $7 billion the Federal Government spends on GP care in this country. Sounds like GP care is a 21st century bargain.

Hospitals don’t function without multiple layers of administration and bureaucracy. Despite best efforts and increased funding over the years, hospitals are now at breaking point. Waiting lists are getting longer by the week. There are now waiting lists to be on a waiting list. Variance of care and treatment is making national headlines.

Still, hardly any politician can afford not to support public and private hospital funding. Any shortcoming in the delivery of clinical services is usually followed by a loud call for ever increasing funding.

There are multiple reasons for it.

First, hospitals are very good at treating patients. Those treatments are often procedure-based and are just expensive. A minute of theatre time at the Fiona Stanley Hospital in Perth is budgeted at $160. So, the cost of 2 minutes of theatre time is more than the Federal Government spends on Medicare for a patient seeking GP care. Not per minute – per year.

One solution of course would be to ask the theatre team to hurry up. Clearly time is money – but it would not do the complex issue justice. We need to have less operations, we need less treatment. We need to focus on maintaining health and we need to focus on prevention. And that has to happen in the community, not hospitals.

Emergency departments are overcrowded. Public and private hospitals struggle to meet treatment targets. It’s a nationwide issue. But have a look at the data from NSW that was made public last week. Compared to the same quarter last year, almost 20 000 additional patients presented to emergency departments. The total number of presentations is a staggering 684 740. That’s for 3 months only and only in one single state. The conservative cost of a single presentation to the emergency department is $250 to the taxpayer. Feel free to do the sums – we’re talking triple digit millions. Again, per quarter. One state only.

Even worse, at times patients are not waiting. They book in at reception, but leave. They are never seen by a doctor in the actual emergency department – yet – the Commonwealth is billed $70 per “did not wait to be seen”. Ultimately those patients are seen by the GP the next day, and I would say, should have been directly referred to the GP when they presented to the emergency department in the first instance. Estimated cost for the government: $15 million per annum. Again, no clinical service, but the taxpayer is charged regardless.

Consumerism and fragmentation of care

Fragmentation and consumerism in health care also increasingly affect the patient experience. And yes, I keep saying that I still specialise in patients – not consumers, clients or users. General practice is a vocation. Not an industrial endpoint. The patient-doctor relationship is special. It’s not a business transaction between a willing seller and the highest bidder. Health is not a tradeable commodity and we should not treat it like one.

Looking at the most recent federally funded health programs, it struck me that is has become commonplace to talk about consumer-centric mental health packages and client-based aged care services. Primary Health Networks are now commissioning bodies for some forms of health services and I sometimes wonder whether these services will be chosen by a computer algorithm and then delivered by a remote-controlled drone. There may even be an app for all of this. How sure are we that we are improving health outcomes, walking on this uncertain path? Are we sold a promise? Of control, independence, autonomy? Maybe. But who benefits?

Never did I think that I could be perceived by either policy-makers or patients as a client manager, who may be paid based on some key performance indicator and consumer feedback. Calling patients consumers, clients or service users is also not the same as empowering them. Dr Jason Tomlinson suggests that doing so is very unlikely to change the prejudices associated with illness and disease, because these prejudices are too deeply historically and socially embedded. The relationships between patients and their GPs have, however, evolved throughout history as traditional hierarchies have changed: patients have become better educated and GPs have been trained to be more patient-centred.

Treating patients as consumers can, of course, create significant problems as the Harvard Business Review points out: First, patients don’t want to be there. People don’t seek out health care without reason (I’d like to add that the number of recreational colonoscopies performed is actually very low). Something is wrong and patients want it fixed.

Second, patients are not equipped to be there. Even when patients are willing to be decision makers, they may not have the tools. At a time of unusual stress, the system asks them to absorb technical information and make difficult decisions that require specialised expertise. When patients are required to be proactive decision makers, the health system is often casting a very reluctant hero into the role.

Third, patients are not in it alone. To design for patients alone is to forget that they are part of a complex system and are often not independent decision makers. Decisions are shaped by other stakeholders: friends and family who offer support, practitioners who provide care and expert advice. Are GPs just meant to be providers selling services to health care consumers? Is it a scenario from a Brave New World where consumers visit a provider for another interchangeable transaction in a commoditised society?

Ultimately this approach will lead to peak fragmentation of health care. Policy makers and program architects need to take a step back and assure us that in their eagerness to consumerise the medical experience, they don’t undermine the quality of care by demanding more of patients then they should be expected to deliver. How come my patients are still asking me: you are my GP, what would you do, doc?

What we GPs do

GPs find joy in small things. And as my colleague Dr Margaret McCartney wrote just last week in the BMJ, small things are indeed big things for us GPs. I’m deliberately quoting her:

“It’s when you say hello to someone who is at the practice not to see you but your practice nurse. But you know these patients, their mothers, their sisters. You know that they are at the practice to have blood tests to monitor the cancer you diagnosed last year. You both know this. The relationship that general practice allows us to form can last decades. They weave between families and overlap across illnesses, presentations, treatment choices and even death. They make it easier to handle uncertainty, to talk about dying, to think about mortality, to grieve, to make rational choices, and to feel joy.”

I’m thinking about the person you have not seen for years, but who returned to the practice to see you because you helped with his depression before. I’m thinking about the baby born after many years of trying, when you exchange smiles with the parents, who know too well the years of tears and infertility. I’m thinking of the bereaved husband, and the wife who came to talk to you about her fears about how he would manage after her death. His wife understood that you would still be around after she died and that you’d still be offering care to her husband.

“If you rip the longitudinal care out of general practice, it’s just a set-up of interactions to be monitored by tick-box targets or analysed as data on ‘activities’. Take the relationships with people out of general practice and you have an unsustainable future. General practice is a risk sink: GPs are the depository of much uncertainty, which allows an affordable health system to exist. But it can only work when it is supported. We make judgements about who we trust, and those judgments are stronger and better when they are formed over time.”

General practice is a long game, characterised by continuity of care, not fragmentation. This benefits patients, society and of course the taxpayer.

GPs are the doctors of first and last resort. We provide continuous and comprehensive care. And GPs want to be responsible for a person’s entire health care needs. That does not mean that GPs are doing absolutely everything. Of course not. But we are preventing fragmentation. Fragmentation of care and the associated poor communication leads to poor health outcomes.

So, what is the value that GPs bring to the health system? Professor Barbara Starfield’s work clearly demonstrates that countries with a strong GP-centred system have much better health outcomes than countries that don’t. It’s not tertiary care and hospitals with the latest and greatest technology that’s achieving that. It’s not the fancy tools. They deliver headlines for the popular press and make national news, but not the positive sustainable outcomes our society deserves. Looking at international evidence – if you increase the number of GPs by one per 10 000 people, the death rate in that community goes down 9%, if you increase the number of non-GP specialists, the number goes up 2%. If you are a GP, you average at least 35% lower cost of care and a 20% lower chance of dying for your patients. General practice improves patient’s self-rated health, it reduces health disparities among populations and reduces the effects of income inequality.

Bottom line: people do better with general practice. So why is that? Why are people doing worse when non-GP specialists are the foundation of care?

Well, one reason is that when specialists get outside their area of expertise, they get dangerous. Ask a cardiologist to manage a patient with pneumonia, a gastroenterologist to treat acute myocardial infarction or a chest physician to treat upper gastrointestinal bleeding – they just don’t do as well as GPs do on any given day.

Continuity of care results in a significantly lower risk of death. Continuity of care also leads to fewer hospital admissions, in particular in patients who suffer from multiple and complex chronic medical conditions.

GPs were traditionally described as gatekeepers of the health system. I think that’s not the appropriate description of what we do, and it almost implies that GPs are a barrier to health or treatment. GPs have evolved to be the stewards of our health system. We enable health by guiding, counselling, advising, comforting, healing and sometimes – treating.

GPs want to spend more time with their patients. Every minute I spend with my patient allows me to obtain more information about the life, concerns, fears and expectations. As a professional I’m trained to put this information into context. Putting information into context over time, I ultimately gain true knowledge of my patients and the more I know about them, the less likely I’m tempted to initiate tests, order procedures or write prescriptions.

Funding for GPs

Total annual health expenditure in Australia is about $145 billion. General practice accounts for just around 5% of that. This includes the funding for Medicare, practice incentive payments and Primary Health Networks. Over 85% of all Australians are seeing their GP at least once per year. If you do the sums, the total funding for comprehensive GP care, no matter over how many visits, is a measly $30.40 per person per month. That’s how much the Federal Government spends on GP care. It’s less than a subscription to Foxtel, or to The Australian.

Over the last decade that figure has been virtually constant, whereas funding for public hospitals has increased over 19% in the last few years. One has to wonder whether general practice has to pay for the infrastructure of hospital medicine. If so, we will inevitably end up with assembly-line medicine in which patients are forced through 6-minute consultations.

I would like to reject the notion of my colleague Dr Pamela Wible who speculates whether general practice is taken hostage to a tertiary care delivery model. One would hope not, as general practice is the solution to rein in the ever-increasing costs of the tertiary hospital sector. The savings that can be gained are obvious: if we reduced hospital admissions by 6%, we would save $2.5 billion every year. One third of emergency department presentations could easily be managed in general practice. The cost savings without compromising quality care would be $1.4 billion every year. Hospital outpatient departments are also providing over 400 000 consultations that could be better provided in general practices. The savings here: $108 million. Three simple and pragmatic measures and the taxpayer would save $4 billion per year.

So where do the savings go? Well, of course I’d say all realised savings should go towards funding general practice (after all general practice only ever gets 5% of total health funding, less than 2% of research funding, but still see over 85% of all Australians at least once per year). But I’d be very happy with half that amount. If we want to shift the norm, direct healthcare funding from the expensive tertiary care system to the more efficient and sustainable general practice system, that’s what we need to do. It would take the pressure off the hospital grid. It would turbocharge the community and electrify general practice. In fact, I like it so much that I’d call it the Snowy Mountain Scheme of General Practice. The benefits would flow immediately (I’m looking at the Prime Minister’s advisor in the audience here…)

But seriously. There are only three levers for funding general practice:

1. Funding can be allocated directly to general practices
2. Funding can be directed to individual general practitioners and
3. Funding can go to directly to patients via a Medicare rebate.

There is no magic. Those are the three funding levers that are available to policy makers and politicians.

Directly funding general practices or general practice systems so far has not had much impact. Practice incentive payments for accredited GP practices, infrastructure grants and small grants for research are cumbersome, complicated, and poorly administered. As outlined above, payments to practices should incentivise systems that support continuity of care. The benefits are obvious to patients and practitioners. Payments should also incentivise better access to care in order to support the drive for continuity. Payments should be flexible.

General practice systems should be incubators for new ideas. Those ideas should address specific issues and concerns in the respective community. A top-heavy, centralised, one-size-fits-all approach defeats the purpose.

Practice systems are also centres of learning and research. Students need to be taught in the real complex world of general practice. And we can’t teach continuity of care in blocks of 2 weeks at a time. If we want to shift the norm of healthcare delivery, we also need to shift the norm in teaching our future GPs.

General practice systems are the natural place of research and exploration. Networks of GP practices will deliver valid research that is applicable to the complex environment we work and live in. If we want to generate the evidence for the delivery of 21^st century healthcare we need to do the research in general practices. Not academic silos. Otherwise 85% of the research will be wasted yet again. We just can’t afford that.

We need to fund a progressive workforce of general practitioners. Too often I am hearing that we need more GPs. The question asked is: how do I get more GPs for my practice? Often this is not the question that should be raised. The question ought to be: why are GPs leaving? Of course, there may be personal factors beyond the community’s control or influence, but there are factors the system could address. If we want to strengthen the continuity of care aspect, direct retention payments to GPs who are committed to their communities are cost-effective and efficient. Let’s be frank. The average income of a GP is now less than the average income of a hospital doctor. There are consequences. Although medial graduates who are entering a career in general practice are not preoccupied by what they can earn, the limited income potential starts to bite shortly after. We need to shift the norm here too if we want to attract the best and brightest for our profession.

Of course, we need to enable patients to see their GP. GPs are the most trusted health professionals in the country with satisfaction rates over 90%. That’s an approval rating most politicians here in the room could only dream of. I guess we must be doing something right.

But, one out of 20 patients are already delaying or avoiding to see their GP due to cost — the main reason being the unfair and nonsensical Medicare rebate freeze. I’m saying nonsensical for a reason. As I mentioned before, patients don’t choose to get sick. And if you are unwell, and can’t afford to see your GP, you will attend the emergency department. The cost there for the taxpayer is multiple times higher than the cost of a standard Medicare rebate to see a GP.

prior to the last federal election, the Victorian state government calculated a cost of an extra $220 million due to additional emergency department presentations and ambulance call-outs as patients would avoid seeing their GP. Bear in mind, lifting the Medicare freeze for GP item numbers would cost only $160 million. That’s nationally. We can’t afford to be penny wise but pound foolish. It does not make sense.

All political parties have now openly stated that they are committed to Medicare and that Medicare deserves to be protected. What that should mean is that funding Medicare should be protected. Specifically, what should be protected is the funding available to patients via the Medicare rebate and the services covered. Medicare rebates should reflect the true value of a service to the patient and the community at large and the actual service should be meaningful, evidence-based and clinically indicated.

We need to take the politics right out of the debate. Medicare does not need political gatekeepers, but Medicare needs genuine stewardship. Stewardship that ensures that Medicare is not fragmented but genuinely of value to taxpayers and patients.

We therefore propose to establish an independent Medicare Authority which would incorporate the MBS review, and therefore make that review continuous and permanent. The independent Medicare Authority would also be tasked with contemporary pricing of individual MBS items based on the value to patients and clinicians. The independent Medicare authority should review Medicare Safety Net thresholds. If we do have a safety net it should be significantly lower for patients who need to see their GP. It would be the right thing to do. The independent Medicare authority should also include the Professional Services Review as well as the Medical Services Advisory Committee. We’ve got to bring those branches together, not drive them further apart. Fragmentation here has the same effect as fragmentation has to the delivery in health care.

Commitment to evidence-based health policies

In my editorial in The Australian a few weeks ago I quoted Professor Brian Able-Smith from the London School of Economics. Decades ago he was asked whether there were any new and significant health care policies. He answered: the only way to organise and pay for health services well is to change the system every second year so nobody feels comfortable in it.

In a rather bipartisan approach GPs and our patients have indeed been shaken, stirred, turned inside out and put in the freezer. The reason? Nothing, in particular, other than politics.

A coherent and comprehensive health policy is a bit like making a cake. One needs quality, evidence-based ingredients. Of course, one needs to add some political flavours – that’s almost inevitable, but if it is all about flavours and not about substance everybody gets sick.

The RACGP is politically agnostic. As an academic medical college we are calling for a commitment to evidence-based health policies. It should not be that difficult.

If ever possible, we should keep politics right out of health care. Because there is no Labor, Liberal, National, Green approach of looking after patients, there should only ever be the methodological, scientifically sound, logical and evidence-based approach to 21^st century health care. That’s what the community expects. That’s what voters expect and that’s what will improve the health of our nation – and that can only ever be in all our interest.

The role of the RACGP is not that of a lobby group. We advocate for the public interest, not personal profits. The basis of our advocacy will always be science. The logical, common sense argument needs to prevail. Not the chequebook.

When we point out a problem, we will also offer a solution. This does not need to happen publicly. It’s possible to be an activist for a cause without being an exhibitionist. But it is our role to raise the level of health literacy among our patients, the public, but also among political decision makers and the press.

Health is essential to advance Australia fair. This is what we advocate for and this is exactly why we are opening our office in the nation’s capital today.

Dr Bastian Seidel is Tasmanian GP. He is President of the Royal Australian College of General Practitioners.

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