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Issue #1465      28 July 2010

Importance of primary health care

Over the last 20 years the bipartisan policy of the major parties has seen the creeping privatisation of health services – including the 30 percent public subsidy for private health insurance which is accelerating the transfer of specialists and administration to the private hospital system. The private health system is growing while the public sector is shrinking. Increasingly the system is based around doctors charging for episodic care on a fee-for-service basis and less and less salaried doctors working in team-based care.

Our frontline health services are failing in prevention and in treating those most in need.

This can be seen in the way thousands of men now have a simple blood test as the sole means of screening for prostate cancer – called Prostatic Specific Antigen (PSA). The test is unreliable. A raised PSA could simply be on the basis of ageing and an enlarging prostate. Monitoring PSA is thus best reserved for advanced prostate cancer. Public authorities advise GPs against relying on a PSA blood test as a screening test; that “it’s more trouble than its worth”. Nevertheless, it is now routinely used by time-poor Aussie GPs as a screening test for men’s health.

By not doing the standard test for prostate disease, a rectal examination, the doctor has also missed the opportunity to screen for bowel cancer – (up to 90 percent of bowel cancers are in the lower end of the bowel which can be reached by the doctors finger).

The problem here is not the PSA test. It is that the current payment system acts as a disincentive to doctors spending time with their patients. It encourages quick, perfunctory care. The result is a less efficient health system and, as in this case, screening gone wrong or the patient being sent off for expensive and unnecessary tests including such tests as a CT scan which is equivalent to radiation exposure of 300 X-Rays.

Doctors know the PSA blood test is unreliable – they order it because it is the practical thing to do in the circumstances of a packed waiting room and where they are probably working alone. Simply put, under the walk-in, walk-out payment system, undressing and examining a patient takes time and costs the doctor money.

To take another example, frail elderly patients in residential aged care need regular careful watching and monitoring of health needs. They are usually on multiple, strong medications, have chronic underlying health problems or they can fall and hurt themselves. Many are depressed – who wouldn’t be? They need close regular monitoring of their diabetes or blood pressure and medications.

However, many GPs are no longer prepared to make the trip to the nursing home. A minority attend but usually only for a quick visit to write up medications on a monthly basis. At the same time the private residential aged care owners find it much cheaper to employ non-nursing trained staff.

When things go wrong, which is often on a daily basis, the easy recourse is for the staff to ring an ambulance and dump the frail, elderly patient on the overrun hospital emergency department (ED) staff. This is a very expensive way to run a health system – as the elderly patient may often end up admitted to hospital. Hospital day costs are $1,500 per day compared with $60 for a GP visit.

It is the way we pay our GPs which is the problem – encouraging isolation and fast throughput rather than the GP working in comprehensive team-based management with nurses and allied health workers. Under the current fee-for-service system, the more patients seen, the higher the doctor’s income.

Put it another way, under the walk-in, walk-out payment system, doctors lose money if they spend time with the patient – or if they have to leave their office to visit the frail elderly.

Thus Australia’s GPs have become fairly good at providing a form of limited care or episodic care – often dominated by the “worried well”. And this is to the exclusion of chronic and complex care, home care and nursing home care. The system is badly skewed towards those in relatively good health and away from those who most need it.

Primary care has become a system with perverse incentives often leading to poor decision making, and an avoidance of those with complex care needs or those with multiple complaints or who would be time consuming for the doctor – known in the trade as “heart sink patients”.

Thus our hospitals increasingly becoming the default in the health system – acting as safety net but also for acute care and elective surgery. The paradox is that long waiting lists are seen to be an indicator of hospital system dysfunction – rather than the other way around, ie failure of front line services. Thus, Labor’s hospital-centric solution to change the way we finance our public hospitals – is, in Rudd speak, “grabbing the wrong end of the pineapple”.

The real solution lies in changing the way we pay the doctor. Only in this way will there be a re-organisation of frontline care services, so that doctors and nurses spend more time with their patients – especially those with chronic and complex care needs, the frail elderly as well as time for proper screening services and preventive care.

Block funding of all complex conditions and care of the elderly would enable comprehensive care in the community and help keep people out of hospital. And isn’t that what a health system should be about? A team-based approach of doctors and nurses and allied health/community care delivering comprehensive care at much lower cost in the community – where it is more appropriate. Just as we have team-based care in hospitals.

Comprehensive care

Progressive reforms to strengthen and extend Medicare with the provision of reformed comprehensive primary care, aged care, mental health services in the community, dental care and much expanded home care services are the way of the future. It is the only way to meet the needs of an ageing population and to contain health costs. The government’s hospital-centric approach to health reform is the way of the past. It is a dead end that will take us down a path to expensive user pays American system of health care.

The solution is a strong and invigorated Primary Care System – building and extending on the access and equity provided by Medicare but ensuring that the “access” is to comprehensive team based care in the community – not GPs forced to work alone in solo practice. Thus the focus of primary care would no longer be on episodic care for the worried and a perfunctory and fast turnstile approach to care for the very sick, the frail elderly and the dying.

Fixing Primary Care and front line services is the only way to fix the hospitals in a sustainable fashion i.e. without eventually leading to rationing and privatisation in the future. Treating people in the community means that our hospitals are left to deal with more appropriate cases such as major trauma, severe illness or elective surgery.

* Dr Con Costa is the national vice-president of the Doctors’ Reform Society. The above is based on extracts taken from a far longer article on the health system and policy published in the latest Australian Marxist Review.  

Next article – Organic Cuba without fossil fuels

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