Aged care reform: slippery slope to generalist demise?

THE Royal Commission into Aged Care Quality and Safety Final Report has shone a spotlight, as was needed, into the experiences of aged residents within a system that is underfunded and undervalued. The Report’s recommendations offer important and, in some cases, divergent approaches to governance, funding and workforce.

Interest in aged care and its quality continues to grow as an increasing proportion of the Australian population is aged 65 years and over. The supply of family caregivers and the hours of caring they have provided appear to be reducing, compounding the need for residential and community care solutions. Within the aged care sector comes the need to provide high quality health services to people in their homes and aged care institutions.

The Commission’s Report alludes to serious concerns about the sufficiency of general practice service provision:

“… the level of service provision by general practitioners is not adequate to meet the needs of people receiving aged care … practitioners are either not visiting people receiving aged care at their residences, or not visiting enough, or not spending enough time with them to provide the care required.” (p114)

The Commissioners noted that the fee-for-service payment model underpinning GP services may be a cause for these concerns. It is true that the way that Medicare is currently designed rewards short term episodic care over the longer complex presentations common in aged residents. Yet, instead of considering how to tweak Medicare to produce better incentives for complex service provision, the Commission recommends the adoption of a new capitation funding system and platform for GPs to provide services for those aged over 65 years with health and care needs. This has major implications for general practice, where the proportion of patient visits made by those aged over 65 years constitutes at least 23.3%.

Recommendation 56 of the Report — “A new primary care model to improve access” — suggests that for aged care patients to receive GP services, they must enrol with a GP who agrees to service all their needs for a set fee, called capitation, where the GP is paid a fee per head. For the GP to take this up requires a separate accreditation process, according to the Commissioners. In return for the capitation payment, the practice would need to guarantee accessible care arrangements including after-hours access, use the My Health Record in conjunction with aged care providers (both residential aged care facilities and providers of home care packages), initiate and take part in regular medication management reviews, and agree to prepare an Aged Care Plan (in collaboration with a geriatrician, the aged care providers, such as residential aged care, or home services, such as nursing or personal care service providers, and others) for each enrolled person.

They would also need to accept any person who wishes to enrol with them (subject to proximity or realistic distance to the practice) to avoid practices cherry-picking eligible patients with the least complex care needs. To receive payment, the practice would report against a range of performance indicators, including rates of immunisation and prescribing. The capitation payment would be reduced by the value of Medicare benefits paid when an enrolled person attended a GP in another practice. This could inadvertently punish GPs who have more limited availability such as those in areas of workforce shortage, working part-time or unable to be available 24/7.

Interestingly, I was always taught in medical school and in general practice that managing ageing patients was the most holistic of general practice and a great way to be part of a health care team to deliver whole of patient “cradle to grave” care, an area that generalist doctors excel in. This model has its foundations in all the background sociodemographic context the GP has on their patient. It is this background that provides the backdrop for safe and high quality clinical decision making, including around a complicated raft of other knowledge of the patient, their family, their medication and risk and compliance profile. But the current Commission’s recommendations require for GPs to now call on specialists (such as psychiatrists and geriatricians) in a prescriptive way to source advice on elements of the care. While GPs normally and regularly seek the advice of specialist colleagues when they need to, enforcing this will truncate both GP autonomy (and therefore interest in participating) and also affect the provision of excellent care, particularly if specialist advice is hard to access in a timely way.

Recommendation 58 – “Access to specialists and other health practitioners through Multidisciplinary Outreach Services” – tries to address this, identifying the need for accessible comprehensive specialist services. The Commissioners suggest that hospital-based or salaried specialists should be assigned to a 24-hour on-call service to aged care patients as part of their work. Timely access to this specialist service is laudable, but rural settings are not mentioned. One would assume this would entail virtual provision given that relevant psychiatrists and geriatrician specialists are in undersupply nationally as well as rare many regions.

While Recommendation 65 – “Restricted prescription of antipsychotics in residential aged care” – notes that specialist input is needed for the aged care plan and initiation of antipsychotic medication, it is unclear whether allowance will be made for qualified rural generalists to take on these roles in contexts where individual specialists are absent and virtual consultations are equally hard to access or are ineffective. Such is the pattern for most other areas of rural health care.

The notion of restricting GP leadership in prescribing antipsychotics to address overprescribing may need some further evaluation. There is an implicit assumption that a one off “expert” specialist consultation will reduce unwarranted prescribing. The implication of mandating specialist involvement is that, due to the prevalence of challenging behaviour among some residential aged care residents, specialists will need to provide 24-hour access to their services to keep residents and staff safe.

As opposed to a specialist-driven model, generalist care has given better access to affordable and accessible primary care reducing mortality and improving patient experience over time. The evidence is clear that a generalist model which coordinates, prioritises and organises care is superior to the involvement of multiple specialists each with a disease- or organ-specific remit without this generalist layer. If the problem is a deficit in the way the generalist model of care is funded for its intent, I suggest we concentrate our focus on valuing that role in solving this problem.

The Commission’s Report provides for further reflections about what quality of care means in this context. It may be that the Commissioners felt that the quality and safety of care could not be improved without introducing more GP regulation. However, alternative and complementary mechanisms will be required in addition and should include funding GPs to do advanced training as part of becoming a provider, akin with GPs being multispecialist (generalist) providers to fit the needs of their communities. Many GPs do develop and support a special interest in aged care, accessing continuing professional development and working at an advanced level. Support for this approach, where special skills are developed and valued, can deliver high quality care.

Instead, the Commission’s proposed model will have significant impacts on the shape of general practice and, therefore, also on medical workforce training and development. It will likely result in an increased demand for various specialty training schemes like geriatrics and see a rise of “aged care corporate GPs”.

Finally, the Commission’s Report must cause reflection about how aged care capitation funding will serve in rural and remote and socio-economically disadvantaged areas of Australia. Towns may have only a small number of residential aged care beds and thus limited care options or appetite for the “aged care practice accreditation”. Imposing the capitation system may reduce the choices for the people who have the greatest relative health burden and need the most primary care to prevent expensive retrievals and hospitalisations. Apart from a lack of specialists willing to serve there, these communities may not have enough GPs, nurses and allied health practitioners, presenting a significant barrier to the implementation of the Commission’s preferred model. The capacity to provide a nationally consistent and agreed model of care must be predicated on provisions for these settings, including their capacity and appetite for digital inclusion.

In conclusion, as this very important topic of high quality accessible, affordable and available primary care is unpacked, it is essential we consider the broader impacts. There may be unintended consequences if the continuity and breadth of much of current general practice activity is reduced in the expectation that a new group of practices will address the poor volume of GP time and services in the aged care sector. If we enforce additional accreditation and compliance on general practice as well as the devaluing and disinvesting in high quality generalist care, we may walk into a future that will accelerate its demise.

Professor Jennifer May is Director of the University of Newcastle’s Department of Rural Health and a practising GP. She oversees the Rural Health Multidisciplinary Training Program in north western NSW, the Tablelands and on the North Coast.

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.