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IF we are to treat our older patients better – in every sense of the word – then general practitioners are the best and most obvious people to do it, but how GPs are remunerated and how they are supported needs to change, according to one of Australia’s leading primary care academics.
Professor Dimity Pond, Professor of General Practice at the University of Newcastle, told InSight+ in an exclusive podcast that Australia’s health care system was “about cure”.
“It’s about finding a problem and addressing that problem and hopefully fixing it, or at least alleviating it,” Professor Pond said.
“When you get older the limitations on life are not curable. We all have to die sometime, and it’s a question of quality of life. An older person might prefer a medication which improves their quality of life even though it might shorten it, and they might make that choice.
“We as a society really need to think about that.”
Professor Pond and Dr Catherine Regan, Senior Lecturer in the University of Newcastle’s Department of Rural Health, have written an open access Perspective for the MJA, which details the importance of the GP’s relationship with older patients, and the importance of addressing complexities of the ageing population.
“In 2017, one-fifth of all presentations to emergency departments was for people aged 65 years and over, but multiple inpatient and outpatient hospital attendances are clearly not an effective way to deal with this growing challenge,” they wrote.
“Primary care providers, with their potential to focus on primary and secondary prevention, their ability to identify disease at an early stage, their knowledge of the patient including their social context and their capacity for ongoing chronic disease management are vital for the health care of this group.
“Moreover, primary care has been shown to be cost-effective.”
In a wide-ranging conversation with InSight+, Professor Pond said involving multidisciplinary teams, including allied health professionals in co-located practices, was an ideal way to provide comprehensive care for complicated patients.
“We need to accept that we don’t know everything about everything,” she said.
“The podiatrist in our practice works down the corridor from me and as [as one of my patients] was hobbling past her, I said: ‘Look this lady … Do you think she might need something done with her feet?’.
“And the podiatrist looked at her and put her head on one side and said: ‘No, I don’t think it’s that. I think it’s muscle tightness at the top of the leg and she needs to see the physio’.
“That was a corridor consultation. You can have a little conversation and you can really start to garner that team effect.
“We have our different skills. I’m interested in dementia, for example, and we’re happy to share patients around, send them down the corridor to the person who has that expertise and then they come back to us.”
Remuneration for GPs treating older patients needs to change, Professor Pond said, and the Medicare Benefits Schedule (MBS) Review was already looking at that.
“There’s no doubt that seeing someone quickly remunerates the GP more because you can see six patients an hour if you spend 10 minutes with each of them, and that’s the same amount of money as seeing four patients an hour for 15 minutes, or three for 20 minutes,” she said.
“For older patients, that’s not right.
“And also, because the GP is the one person in the system who looks at all the different problems of that person, not just their one body system that you’re concentrating on, but the whole issue. That takes a lot of working around and thinking through sometimes.
“The MBS Review is looking at longer consultations for older people in response to submissions. [They’re also] looking at care planning involving the multidisciplinary team,” Professor Pond said.
“To really work your way through a care plan properly and get input from the other folk in the care plan [can] take quite a lot longer. Maybe that needs to turn into a case conference … they turn out to be hugely valuable – time consuming to organise … but really, really valuable.”
Residential aged care facilities (RACFs) were another area requiring reform in order to improve quality of life for older Australians, Professor Pond said.
“Two systems collide with residential aged care,” she said.
“The system that’s running the facility needs to be cost-effective, possibly profit-making but certainly cost-effective. Decisions may be made by people who are not very well informed about aged care needs and have a view, which sometimes the government seems to have as well, that this is a nice home-like environment for lovely old people who are just pottering around and don’t need anything particularly.”
Combined with a low number of staff well trained in nursing and medical management, a lack of allied health access, a GP who can only visit outside their regular clinic hours, a lack of comprehensive medical records, and patients with cognitive impairment, insufficient care is almost guaranteed.
“We need to bite the bullet and provide more funding for residential aged care,” Professor Pond said.
“[RACFs have] a lot of residents with complex needs because everyone’s living so much longer. They need good nursing care and they need nurses who understand dementia.
“I would put a clinician on the board of every nursing home in Australia and empower them, in some way, to ensure that their comments, questions and suggestions have to be taken into account. Because a board that consists of money people could not possibly understand [the complex needs of the residents].”
The My Aged Care website, a new design of which Professor Pond helped beta test, remains a challenging proposition for older people, particularly those over 80 years of age, and those with dementia, she said.
“The whole concept of having a gateway like that on the web doesn’t particularly gel very well with the demographic that we’re talking about. Maybe in another 20 years it’ll be better, maybe not.
“And then also My Aged Care doesn’t deal with dementia.”
In the end, caring for older patients remains a tightrope walk between patient-centred care, and guiding older, potentially frail or cognitively impaired patients through medical decisions and their consequences.
“As a person who’s in the second half of their 60s, I am looking forward to having a say in what I want and don’t want, especially if I end up in residential aged care,” said Professor Pond.
“I will want my values about medications and so on taken into account. That’s important.
“But if I have dementia and I say, ‘I don’t want that dressing on my toe’, the carer says, ‘Well you have a right to say no to that’.
“But then the toe has to be cut off eventually because it got gangrenous. I wasn’t able to understand the implications of my decision. That’s where the health understanding comes in.
“So, there’s a tension between that patient-centered care, empowering the individual to make decisions, and that understanding from health practitioners that there will be health consequences for that decision.”
Professor Pond advocated for the creation of medical “navigators” – care coordinators out in the community to help patients navigate the health system, especially for older people and those with dementia.
“We do have that for younger onset dementia, a care worker program, but we need it for people not just with dementia but older people with complex multimorbidity that need support, who have to work with My Aged Care.
“Or else we need to empower practice nurses, train them up and pay them to help people through the system,” she said.
“We need a radical change in the way we look at [caring for older patients].”
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I am a GP with a special interest in Aged Care and I completely agree with the article and comments. Provision of excellent primary care to the elderly takes a thorough, compassionate and team-based approach. With this in mind, consultations need to be longer, care plans have greater importance, and an understanding of available services (and how to access them) – is imperative. Individualisation of care is also very important for these complex patients to better provide “person centred care”. Additional to this, is the enormous administrative burden and hours spent communicating with family and nursing home staff which often comes with no renumeration at all. The idea of case conferencing is wonderful but the practicality is not straightforward. I agree that MBS renumeration is a major issue. Colleagues opt out of nursing home patients, because these invariably require out-of-hours time and excessive administration which is poorly renumerated. I think there need to be item numbers available to include payment for administrative tasks and phone calls to family members (guardians) as well as incentives for thorough care plans and liaison.
As someone who has worked in aged care for 20 or so years I have seen many changes. But still not quite enough.
The most pressing issues I believe are inadequate numbers of capable nursing staff and undereducated carers.
I believe if we increase the numbers and capabilities of staff in aged care we have a chance of providing care of a reasonable standard.
I am a social worker working in a rehabilitation hospital. On a daily basis I come across older patients being faced with a difficult future. Most people are ill prepared for aging, and our infrastructure is not coping with our aging population. Difficulty in accepting that one needs increased care is a common issue. Most people would like to age in their own homes, but often require more care than can be provided by Home Care Packages…. and of course there is a long wait for a package. Residential Aged Care is certainly not perfect but often it is the only option for a frail older person. Unfortunately, as with any form of institutionalization, a culture develops whereby the smooth running of a facility overrides individual needs. the more complex the care, the less control the older person seems to have. eg, eat when institution says, wait for assistance for toileting–sometimes told to ‘go in your pad”, addressed like a child at times, and of course a lack of training and understanding in working with people with dementia. I don’t have the answers, but until Residential Aged care facilities are obliged to have a trained multi disciplinary staff, the overall standard of care will not improve.
Aged care is slow, bureaucratic, and lacks of empathy and understanding of the needs of older people. My husband and carer broke his hip on the 27th June . Next day, I had an appointment with the GP. I was in shock having to attend to so many things and the flu making its way into me. I asked for some help in times of stress. The GP said: ‘I’ll contact somebody. They’ll be in touch with you’. ‘This is all what we have time for today’. Nobody contacted me. I phoned Aged Care in Ballarat and of course they could not send any extra help before, I have been promised, the 28 days after my husband broke his hip. I am 81, my husband is 76. Both with chronic diseases and no family. Coles online delivered food and the neighbor in unit 1 takes the bin out on Thursdays. Friends and acquaintances shine by their absence.
I agree that the system needs an overhaul. I am a GP in a group practice with number of eldey patients. I also care for my elderly parents who live with me. My mother has dementia and navigating the system to find appropriate care at home has been a nightmare. As a GP I feel helpless supporting the elderly carers who are looking after their partner with dementia. I agree with the author about the need to support primary care better to accommodate the older person’s health and welfare needs. Remuneration in GP land is the elephant in the room that no one talks about.
I agree that primary care is the key but primary care needs to be reorganised:
. in the community we need to move to something like a Person-centred Medical Care Home with each older person with multiple chronic diseases having a Care Coordinator. The Primary Care Physician would be supported by a range on Nurse Specialists and Allied Health, including an Exercise Physiologist and gym. Primary Care Dementia Nurses and a range of appropriate specialists (e.g. Diabetic Physician, Geriatrician, Rheumatologist) would also visit the Medical Care Home.
. all residential aged care facilities should have a Nurse Practitioner who manages the basic physical health problems and a Dementia Nurse Specialist to assess and manage complex behaviours.
There is enormous value in spending time in the racf where your patients are, liaising with staff and becoming familiar to patients, especially those with dementia. However it is poorly remunerated. If I see more than 16 patients I am paid less per consultation even though by being available for a full day enables better communication than squeezing patients in around a busy GP day. Not to mention communication with families and specialists. Agreed that the extensive admin time needs remuneration.
Aged Care should not be a ‘for profit’ industry. This attracts people who see the elderly as potentially lucrative – having access to Government money and assets of their own and how can this money be channelled in to their own bank accounts.
Cheap food in aged care
Dinner at 5pm so no kitchen staff late in the day
Minimal numbers of trained staff
Turn call bells off as quickly as possible but don’t employ enough staff to actually attend to the resident’s need in a timely manner – usually the toilet.
Employ a physio to tick the boxes but no one gets rehab in ACFs. Using a wheelchair which the resident can purchase makes things easier.
It goes on….
Problem is totally funding related. Not just the face to face time necessary, which is inadequately remunerated, but in addition, the extensive admin and liasing with other providers, and family, which is totally unfunded. The practice l recently left evolved the policy of sending the elderly with comorbodities to ED, when many could be appropriately managed in GP. These complex patients place huge financial demands on practices. It’s the funding model that is totally outmoded and inappropriate, and the patients suffer as a result.
These comments reflect my everyday practice, including the benefit, which I had not forseen, of having a podiatrist down the hall. I thought the GP was supposed to be the navigator for all patients, including those in the RACF. We are within our rights to be remunerated for the time it takes to do so.