Who’s really screwing GPs and their patients

14 minute read

While federal government ‘owns’ general practice and primary care, it’s actually state governments who are royally shafting the primary care sector. Here’s how.

We’ve launched a very big new venture here at The Moose Republic: a sister publication to The Medical Republic called Health Services Daily.

TMR talks primarily to GPs but Health Services Daily goes wide and into the big money, the power broking and the policy making of state and federal government – most of which is, unsurprisingly, focused on hospital planning and management and everything that spins around the enormous gravitational pull of this ~$40 billion in healthcare spend each year.

That means of course that Health Services Daily does cover general practice as well PHNs, specialists, allied health and all the other punters who are essentially spinning around this huge gravitational mass of power, politics and money.

We’ve been on the edges of this world for a few years now through a digital health and reform events brand called Wild Health, so we already had a worrying picture of how money was actually flowing in Australian healthcare and why.

But when you do a daily news service you soon start connecting dots, and when you step back and start looking seriously at the whole dynamic of money, politics and power in healthcare, you quickly understand a few scary truths about what politicians constantly say to us about general practice and the future of healthcare for all Australians, and what they actually do.

Put another way, GPs are muggles in a world run by the wizards and witches of state and federal government and business, who are drawn to and guided by the gravitational pull of the money we spend on, and the political leverage you get from, hospitals.

Here’s the increasingly obvious and scary part: it’s the same wizards and witches community which has brought us all the PWC tax scandal and Robodebt. Power brokers in government schmoozing just a little too much with power brokers in business and the public service.

State politicians are dementors

There are obviously good wizards and bad ones, but as far as state governments and state politicians are concerned, well, they’re largely in the realm of dementors (very very bad guys, for those few people who never read Harry Potter to their kids).

The big difference between a dementor and a state politician and policy maker is that the state politicians, and their now captive public service apparatchiks (captive like the Department of Human Services was captive to our last liberal federal government), aren’t scary looking or ominous at all.

Someone needs to start shining a light on what the states actually do with $40 billion each year in hospital money

They all put out that they love general practice and are doing everything they can to help it, in order to help their constituents, as we all know that general practice is the ultimate secret to managing chronic care and care in the community.

Then they say, if we sort general practice out properly, we can flip the model from managing care in massively expensive hospitals to managing it largely out of hospitals in the community through prevention.

Bricks not clicks

A hugely valuable insight into this state government-sanctioned poppycock was provided this week in a session of the global digital health conference MedInfo23 held in Sydney, where Elizabeth Koff, immediate past secretary of health in NSW and now CEO of Telstra Health, lifted the veil alarmingly on what really goes on inside the planning walls of a state health department.

Koff told the audience of digital health professionals they had an uphill battle transforming the system via digital technologies, as state governments remained obsessed with brick-and-mortar hospitals as a way to win the love of their constituents.

“Bricks not clicks is still their focus,” Koff said, citing how difficult she had found it to try to convince policymakers to open their wallets a lot more to build out the sort of digital infrastructure that might one day connect hospitals properly to the community, especially through better connection to GPs and aged care.

The following day MedInfo featured a session where six of our top state eHealth chiefs got to tell everyone what they were doing to improve the healthcare of their states.

The panel were all smart and accomplished technical managers. They all described some amazing programs they had in play, and strategy roadmaps that made you feel they knew their stuff.

But it was easy to get carried away with the rhetoric and razzle dazzle of the session.

I was woken up to this fact when in question time, GP Rob Hosking asked the panel what they were doing about connecting their big shiny hospitals and new multi-billion-dollar EMRs to the general practice community.

At that point I realised that in every presentation among the six, not one of these eHealth leaders had properly addressed how their hospitals connected to the community. It had all been about digital health programs within hospitals and between hospitals.

In this world, nothing exists outside the hospitals and hospital networks.

When eHealth chiefs talk about interoperability and data sharing, they are almost always talking about hospitals talking to hospital patients and hospitals talking to other hospitals in that state.

GPs are an afterthought at best.

In a manner, Hosking had exposed the fundamental flaw of our national healthcare funding paradigm: the states are funded to do hospitals not healthcare systems.

If you’ve watched all the press about state governments pork barrelling and boondoggling to win elections, and then watched some significant stakeholders, even premiers, coming out and saying that it’s OK to do that, it’s just state politics, then it should hardly be surprising that the money they get to run hospitals is being used as a pork barrel to win elections rather than fix healthcare properly in their state.

State governments are taking our hard-earned taxes and rather than fixing the massive disconnect between hospitals and GPs (and other important parts of the healthcare system such as aged care), which would go a long way towards moving us all to a future where chronic care management and value-based care are actually feasible, they are spending it on bribing voters to help them win their next election.

This is public corruption, writ large.

State politicians are diverting our money for largely personal gain.

To be clear, none of those eHealth chiefs in the panel mentioned above are actively involved in this. They are mostly doing a great job for what they are being asked to do.

Policy people in state governments aren’t really guiding this dynamic either.

But both these groups are captive to it in some way.

And there lies a big problem.

It’s not quite the capture dynamics of the Commonwealth public service that have now been made public in the Robodebt inquiry, but it’s not unrelated either.

If politicians keep threatening the jobs of public servants who don’t toe the line, what do you do if you’re a public servant?

It’s very rock/hard place.

The bad actors are mostly the politicians.

That the eHealth chiefs in the panel described above are captives of a system being warped at the top feels increasingly obvious.  

In this panel session they all arced up seriously when it was suggested they weren’t really addressing connectivity to GPs or aged care.

In fact, they were so upset at the suggestion you almost got the impression that they really believe that are addressing the problem in their work.

They might think they are but they aren’t.

They can’t.

They have not been given the remit nor the money to do it by their state government minders.

Ask Elizabeth Koff, who used to run the largest healthcare government business in the southern hemisphere. The dynamic whereby senior state politicians warp our healthcare system out of shape in a very bad way is real.

Of course, this is a very dense, complex and long game of institutionalised public corruption that organisations like ICAC in NSW, the CCC in Queensland and our new federal NACC will never be able to pin on anyone.

Remember also, all the public is seeing are big new shiny hospitals being built everywhere (nothing not to love about that if you are Joe Public), as well as a bevvy of fill-in, scraped-together, smokescreen “urgent care clinics” designed to baffle everyone into thinking that state governments are addressing our healthcare system’s biggest emerging issue: the breakdown of the general practice sector and its increasing isolation from the hospital sector and aged care.

How can this change?

The sort of dynamic I’m describing here seems culturally and socially systemic in parts of certain state governments.

It feels like some of it goes back to the Rum Rebellion.

Fish are friends – so is the federal government now

Borrowing randomly from another movie franchise (Finding Nemo this time), a lot of GPs might be surprised to learn that where for the past decade or so the federal government was playing games with GPs much like the state governments described above are, now it is suddenly caring quite a bit about the future of GPs.

I’m reminded of the scene where Bruce the shark and his shark friends are all attending the equivalent of an AA meeting to remind themselves that “fish are friends, not food”.

It’s a little like that in Canberra at the moment. Politicians that would normally be looking at the GP sector as pawns to be used in a game of getting elected (food), have suddenly found sobriety in the horrible realisation that if the GP sector genuinely does fold beneath them, they are going to be in a very big world of hurt.

You can probably put this awakening down to a single intervention by a past RACGP president, who broke ranks and tradition in some fit of pique and told all member doctors that the gig was finally up, and that everyone should stop bulk billing pretty much immediately.

A lot did.

And the political dominoes started to tumble pretty quickly after that.

Also, maybe the new Labor government is actually idealistic and well meaning, and wants to change things for the better, so they’re listening and genuinely trying to figure out what is wrong.

Compare this to the last Liberal government and the dynamic they managed to imbed into the public service that resulted in Robodebt and the PWC scandal.

In this scene, Mark Butler is Bruce the shark.

He’s actually got a gentle soul, but as a big swinging political dick now (a shark), his natural instinct is to eat the fish (GPs et al.). But he’s doing his darndest to kick that habit – for now at least – because he knows it’s the wrong thing to do and he wants to do good.

It’s not clear how long such a dynamic might last, but GPs certainly look like they have a window here where the federal government is listening and trying to help.

Show me the money

It’s hard to help, of course, if you don’t have any money.

So far Butler and Co. don’t have a lot of money to help. They are likely waiting for a second term.

But what Butler and certain highly placed policy people in the Department of Health and Aged Care understand very well is that the equation of sending nearly $40 billion to the states each year to spend on hospitals, and then only spending $11 billion on GPs, is not a very balanced one if you’re serious about the sort of system reform you’re going to need to actually shift focus from acute to preventative and value-based care.

What could Butler do if he gets cocky enough here?

The obvious play is to say to the states at some point: if you don’t start connecting to the GP community, and others, properly, soon, we are going to start holding back some money.

There is some evidence that this seemingly outrageous and obtuse political play is already happening, even if in a very gentle way.

DoHAC this week made it pretty clear that it is working on legislation that will require every healthcare provider in the country to upgrade their digital platforms to a minimum standard of modern web-based data sharing, which will enable real time meaningful data sharing between all points of the system – both between providers and between providers and patients.

As a GP you probably aren’t going to know what the 21st Century Cures Act in the United States is or what it did, but this is what your new federal government has in mind.

If it succeeds in this quite significant pivot from what we’ve been doing in the past to achieve digital health connectivity, one day GPs might actually be properly connected to hospitals, aged care and perhaps even the NDIS.

If that happens, GPs aren’t going to have any problems with their business models and status in the system.

They will become the true centre of how our healthcare system works, just as all the politicians today say they should be while doing absolutely nothing meaningful to bring that promise about.

This initiative by DoHAC is a surreptitious way to bend the states to federal will on bringing GPs into the tent, without necessarily having to give the states a lot more money.

If it pans out like the 21st Centure Cures Act has panned out in the US it means that every hospital in every state would have to upgrade its systems to be able to share their data properly with GPs in real time.

That is actually going to take some extra money, so we will see what happens.

From a GP point of view, this initiative from the federal government is also going to have a direct impact, so watch out for what might be coming.

The same legislative edict that will force hospitals to upgrade their software platforms to share data properly in the system, will be applied to GPs and their patient management systems as well.

That means that Medical Director, Best Practice and Zed Med will all have to either rebuild their products entirely within a period of time to meet these minimum standards of data sharing, or build wraparound translation layers (if you’re technical, open APIs and FHIR interfaces).

Best Practice is already starting on this journey with an initiative called Halo Direct.

Medical Director has a cloud product called Helix, which if it doesn’t do this already, will undoubtably be upgraded so it does.

Who will pay for this?

That’s a pretty interesting question for Mark “Bruce” Butler.

Given the dire state of most GP practices around the country and the increasing red tape load, could the federal government really impose a technology upgrade tax on GPs?

Probably not.

Probably they will need to come to the party, as they did in 1994 when the first ePIP funded most GPs to go out and buy a computer to do electronic script writing.

Back to the dementors

The GP colleges and the AMA have to think much more carefully about a dynamic in which the federal government is probably now genuinely on their side, and the state governments remain systemically corrupt as far as responsible healthcare spending is concerned.

These organisations need to try to figure out how to do a Karen Price on state governments.

They need to work out how to turn patients against them.

Professor Price did it by shutting down bulk billing, which had the downstream effect of the electorate bleating that healthcare isn’t free any more and starting to blame the federal government for it.

State governments are the significant problem now.

Traditionally, the AMA, RACGP and ACRRM have put all their energy into attacking the federal government because, what with Medicare rebate freezes and the like, it seemed the obvious place to start.

These organisations now have to read the tea leaves, and realise that the federal government, even DoHAC is largely on their side now and they have a common new enemy: state governments who boondoggle their electorates with more and more hospitals, pretend they are helping with Band-Aid ineffective initiatives like urgent care clinics, and brazenly ignore the most obvious and solvable problem our healthcare system is facing.

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