COVID-19: view from a rural bunker, part 2

“Nothing is so permanent as a temporary government measure.”

Milton Friedman

WHEN we look back on the coronavirus disease 2019 (COVID-19) pandemic, much shall be written on how hitherto common practices changed for good. One of the challenges for the medical profession is to defend the changes that are for the better while shelving those that have not helped us best care for our patients.

It has been enlightening to see that the monolithic Treasury, Council of Australian Governments, the Australian Health Practitioner Regulation Agency (AHPRA), health departments, Local Health Districts (LHDs) and Primary Health Networks (PHNs) can move fast when they are told to by the politicians.

Telehealth

Suddenly telehealth becomes possible after years of lobbying by doctors and others. However, telehealth has gone through at least four iterations since it was introduced as a temporary measure a few weeks ago. Every iteration means practices need to re-educate, create new practice policies etc. We did not need this addition to our already complicated lives right now: it should have been open access and no strings attached from Day 1 of the crisis. Medicare and the Professional Services Review have systems in place to catch rorters, so that should not have slowed the full roll-out of telehealth.

Funding models

I strongly disagree with the recent InSight+ article on supposed fault lines in our system.

Fee-for-service may have some faults, but it remains agile and flexible and keeps red tape to a minimum. It has in fact served us well during this crisis.

Any perception that it has not served us well is, in reality, a result of the red tape accompanying fee-for-service in terms of copayments and item descriptors.

If patients were allowed to simply pay a copayment, life for patients and practice staff would be much simpler and efficient, rather than the time-consuming process for obtaining a Medicare rebate.

Somehow copayments are permitted for some health services, such as pharmacy, dentistry and allied health but remained blocked for medical services.

The fact that the telehealth items mandate compulsory bulk-billing for some patients is of concern, as this is not at all in the spirit of Medicare.

Continuing professional development

AHPRA can suddenly be flexible with retired clinicians and students, whereas in the past when senior doctors were calling for such flexibility it fell on deaf ears. Now a number of them are having their registrations restored, on a new pandemic subregister, whether they’ve asked for it or not.

As of 6 April, AHPRA had yet to give a clear directive on continuing professional development (CPD). This is unacceptable, too slow and demonstrates that the AHPRA model is cumbersome. For how can registration be opened up so swiftly and yet a ruling on CPD be so slow?

As this year is the start of the new professional development triennium for general practitioners, most will have met their CPD requirements for the previous triennium, and similarly medical practitioners who need to meet annual professional development requirements would have met these by the end of last year. This should be more than enough to satisfy requirements for a year or two. Considering that most courses and conferences have been cancelled for the remainder of the year, AHPRA should grant a 1–2 year exemption on CPD immediately. Clinicians are presently anxious enough without needing the anxiety of AHPRA compliance.

Accreditation of hospitals and practices

The abovementioned principles also apply to practice accreditation. A definite, unambiguous declaration from the accreditation bodies and colleges is required.

Credentialing and clinical privileges

The LHDs need to smarten up and speed up their credentialing of clinicians. Now is not the time to be stalling on clinical privileging and staff appointments.

You only have to look at the websites of many LHDs to see their reliance on locum agencies – a real, not imaginary, fault line in service delivery.

The pandemic has resulted in more command and control protocols with respect to clinical practice, under the guises of “safety”, “joint decision making”, “risk management” and “resource management”. While these trigger words and principles are valid and necessary, we have to be vigilant with respect to LHD overreach and ensure that such measures are temporary.

Almost all elective surgery has been cancelled, for good reason. However, the decision-making process involving who determines and what defines a procedure as elective versus urgent versus risky is the issue.

Are such decisions being made by experienced, frontline clinicians who know the patients and understand the procedures and risks? Or are these decisions being made by administrators, accountants and advisors who are heavy with the regulatory power but light on clinical knowledge?

Gastroscopies and dental procedures best highlight the dilemma. Both involve the upper aerodigestive tract and have the potential to create aerosols that may carry the novel coronavirus. A gastroscopy that is cancelled or postponed may result in an oesophageal or gastric cancer that goes from treatable to terminal. An untreated dental infection may trigger rheumatic fever or a septicaemia. When will we get to a stage in the pandemic when these restrictions could be lifted and elective surgery restarted, and who makes that decision?

Indemnity

State governments are bolstering their indemnity schemes to cover medical officers in the event of litigation in situations such as those described above. However, these extensions of indemnity cover are untested. Moreover, they need to be clearly defined and explained to clinicians and have very open-ended terms of limits of liability.

It is also essential that GPs, dentists and allied health practitioners referring patients in good faith to hospital services are also covered if patients suffer adverse outcomes in the event of LHDs delaying treatment.

Our big investments in health: some look shaky

Over the past decade, billions of dollars have been spent on the My Health Record and PHNs.

Sadly, in this time of crisis, these investments do not appear to be serving us well or showing a decent return on investment.

By now, My Health Record should have been well established in both primary care and the hospital settings. While GPs have made great strides in uploading for the millions of Australians registered, the evidence suggests that hospitals are hardly accessing the information. This means GPs are regularly called by hospitals (usually busy junior doctors), chasing information that is already uploaded on the My Health Record.

PHNs were tasked with distributing personal protective equipment. Unfortunately, in my experience, GP practices have had to rely on their own devices to adequately stock themselves with masks, gowns and hand sanitiser, often at great time and money expense. I’ve been left scratching my head as to why this task was given to PHNs in the first place.

Even more puzzling has been the decision to extend financial support to struggling GP practices via the Practice Incentives Program (PPI) Quality Improvement (QI). As the PIP QI relies on PHNs to gather practice data, it appears that, during this pandemic, there is a push to consolidate and expand the presence of PHNs in general practices.

This is not something that all general practices agree with or welcome. The QI is still a new beast and the public has not yet had the opportunity to appreciate what this data sharing really means.

In my mind, a fairer way to help GP practices get over the financial burden of the pandemic would have been a blanket payment to all practices, regardless of PIP or QI enrolment.

In conclusion, I cannot help but agree with Professor Nick Talley’s article a few weeks ago: the regulators and bureaucracy must get out of the way!

Dr Aniello Iannuzzi is a Visiting Medical Officer at Coonabarabran District Hospital, a GP, and a Clinical Associate Professor at the University of Sydney and University of New England. He is Chair of the Australian Doctors’ Federation.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.