Defund the PHNs and put the money into rebates, is one modest proposal.
The divide between hospitals and primary care is not a gap, it’s a black hole, says Dr Aniello Iannuzzi.
He’s a GP in Coonabarabran in outback NSW, where – fittingly for the state’s stargazing capital – they seem to have bridged this astronomical divide.
We asked him how, and the answers are surprisingly straightforward.
TMR: Why should GPs be working in hospitals?
AI: The patient experience profoundly improves [when they do]. In the big hospitals, provision of care is so super-specialised and fragmented that patients have an array of doctors whom they struggle to keep track of. Treatment for simple needs is delayed and you are hard pressed to find a doctor who can bring it all together and get the care coordinated.
Generalists, however, can multitask and sort out more things at once.
For example, say a person breaks their legs in a car accident. They’re sitting on the orthopaedic ward for a week or two and let’s say they happen to be a diabetic and their sugars are high, just to a minor degree. What happens in the big hospitals is that the patient has to wait for an endocrinology registrar to see them, then the endocrinology consultant – which is really expensive care.
Then perhaps the patient gets a rash from being on those bedsheets for too long, or has reacted to the wound dressings. They must then wait for a dermatologist.
This is all expensive treatment. Whereas if you had a GP in the hospital, a lot of this simple stuff could be treated early, which also keeps the admission shorter and saves a heap of money.
I see what you’re saying …
Another example is a man who presents to the emergency department with a cough and fever, who is overweight and also happens to be depressed.
What happens next is a literal reverse auction. Psychiatrists will insist that they can’t take the patient because it’s more of a respiratory problem. The respiratory specialists say “Oo, look, it’s easy to put them on antibiotics but we need to send them to the psychiatrist because that the more important problem.”
The poor man sits in the ED for hours and days, while everyone fights over who doesn’t want him.
When you’ve got generalists in a hospital, they just admit the man and sort it out. One person responsible for both problems. That’s what we do in Coonabarabran Hospital. It’s just common sense.
Many hospitals have general physicians and general surgeons.
Yes, but you look at those other doctors and their exclusion criteria are always bigger than their inclusion criteria. In the example of the man with a cough, overweight and depression, the general physician will say “Oh no, that’s mental health, that’s not for me”.
In the first example – patient with broken legs, skin rash and high sugar levels – the general physician may say: “Oh no, that’s dermatology. I’m a general physician, I’ll do the sugar but not the skin.”
GPs, particularly rural GPs that do hospital work, have a broad skill set that is very useful. They’re efficient both in terms of money and in terms of time, because we can do all these things concurrently.
From the health policy and economics point of view, the value for money is far superior to any of the other specialties.
That could improve hospital outcomes but it’s still not the patient’s regular GP.
No, but for a start, the patient is ahead of the game because they’ve had better care.
Secondly, when a GP is summarising the medications and discharge letters they know how to do that.
In hospitals, even experienced specialists don’t know the PBS, they don’t know the Medicare system. It’s embarrassing. It’s the dirty washing that no one wants to talk about.
You get discharge letters and discharge scripts that are written wrongly, are unrealistic about when the patient can see a GP. The specialists have no understanding what can and can’t be done in general practice.
That sounds a bit harsh?
Well, you shouldn’t give a patient a discharge letter that says see your GP in two days if they could take eight days to get into a GP. So instead, you’ve got to put together a plan that allows for that.
You don’t just give the patient a discharge letter that says to go get an MRI of their shoulder that’s going to cost them $300. Whereas, if you get the orthopaedic surgeon in the hospital to sign the MRI request form it will be covered on Medicare.
Things like this happen all the time. GPs understand how the MBS works. The specialists just don’t get it.
How can we bridge this chasm, then, between hospitals and general practice?
The way you bridge the gap is to treat GPs as equals, and not keep treating them as an underclass to other specialisations.
To do that, GPs need to take an active and meaningful role in the universities and the teaching hospitals, as they did in the past. This is where culture is formed and careers are forged. That would put us back into good standing among our specialist colleagues.
It also does require GPs to step up as well. They’ve got to stop playing the victims and remember what it means to be a general practitioner.
In regional, remote and rural areas, that chasm between hospital and general practice isn’t as apparent. Some would argue it isn’t a problem at all because GPs still do have a role in these settings. Non-GP specialists see GPs as having a meaningful role to play in the hospital setting.
The other way we can bridge the gap more meaningfully is by utilising GPs more in setting policies at the hospital level. State and territory health departments need to engage GPs better in policy development.
These are simple solutions that require a little bit of political will and humility on the part of policy makers and our other specialist colleagues within the medical profession.
Why aren’t there GPs in hospitals in the cities?
That’s a very good question and some of this even predates my career. I’m sure it’s multifactorial, as many of these things are.
If you were to dispassionately look at ED presentations, and if you actually understood what GPs can and can’t do, I think you would find that at least half of the presentations could or should have been treatable by a GP.
That’s not to say that we should close EDs to those patients, but either the ED physicians have to broaden their skill set or the hospitals need to be more accommodating to GPs. It ultimately all makes for a more efficient and satisfying patient journey.
Will urgent care clinics help bridge the gap? They will be staffed, in part, by GPs.
The urgent care clinics are probably going to turn out like the super clinics – suck up a lot of money and there’ll be very little to show for it.
First, they’re not offering continuity of care – there’s not the scope of a hospital to admit and keep patients for a certain amount of time.
It’s also expensive. How is it that the government can allocate $200 to $300 per patient episode for an urgent care clinic but also deems that a GP consult in a private office is only worth $41? This is such a nonsense.
Then you compare it to the cost of an ED presentation, which is $600 to $700 – you’ve got very distorted price signals. This will incentivise a certain style of a doctor to work there and it’s going to incentivise a certain kind of patient. The patients will ultimately triage themselves, where they feel they’re going to get efficiency and value for money, but the care won’t be as good as seeing a regular GP because you don’t have the follow-up.
If you could directly advise Mark Butler what would you say?
Defund public health networks and put that money into the rebate. It’ll be the best thing they could do. The college of GPs says the same thing, but maybe too politely.
They’ve got all the controversy over poor governance that, again, people just whisper quietly behind the scenes, and the Department of Health has to keep putting out these bushfires. We all know what happens, but they try and pretend it doesn’t.
PHNs have very little to show [for their funding]. They’re another layer of paperwork and obstruction and interference.
We’ve also got the whole issue of access to confidential data, which doesn’t seem to be for any good purpose. Defund them and put it into general practice.
Surely PHNs add some value in some way?
I’ve never seen it.
Wild card question: Would you rather be funnier, smarter or more athletic?
I would rather be athletic because it’s something I’ve never been and never will be. So it’s something that I can never attain. As for smarter and funnier – I have had brief excursions into both those possibilities. However, athleticism is something that’s always been on the wish list for me as I like to follow soccer.
You could play soccer for Australia at the next Olympics!
I wouldn’t embarrass my country like that.
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