Fears aged care antipsychotics proposal could impede patient care

Anastasia Tsirtsakis

2/03/2021 5:22:04 PM

The royal commission’s recommendation would restrict GPs’ ability to prescribe antipsychotics for people receiving residential aged care.

Older woman holding a pill.
The proposed recommendation is due to come in on 1 November.

The move to amend the Pharmaceutical Benefits Scheme (PBS) Schedule has set off alarm bells for the RACGP, which has previously opposed increased regulation of GPs wanting to prescribe antipsychotic medications.
The proposal, included in the Royal Commission into Aged Care Quality and Safety’s final report, would see GPs only permitted to issue repeat prescriptions of antipsychotics as a pharmaceutical benefit for up to a year after the date of the initial prescription. If the recommendation is accepted, it would come into effect by 1 November.
However, RACGP President Dr Karen Price has taken a clear stance against the proposal.
‘When it comes to antipsychotic medications, the RACGP does not support the proposal by Counsel Assisting the royal commission to restrict GPs from prescribing,’ she said.
‘We believe that the increasing demand for geriatricians and psychiatrists may actually exacerbate current issues with access and deny the appropriate prescription of antipsychotics.’
Dr Khayyam Altaf, Chair of the RACGP Specific Interests Aged Care network, told newsGP that a lack of access is certainly among the concerns being expressed by GPs on the ground – especially in rural and remote parts of the country.
‘Geriatricians don’t have the access or availability that GPs have,’ he said.
‘The difficulties I’m describing from the metropolitan location, are going to multiply when you think rural – even at the best of times, they struggle. Doctors were telling me yesterday that compared to metropolitan areas, they’ll [really] struggle to get a geriatrician.
‘It’s a significant risk that we could actually worsen patient care, as opposed to improve it.’
Dr Altaf says the proposal is a counterintuitive move when the focus should be on upskilling the GP workforce.
‘GPs have been prescribing psychotropics or antipsychotics safely and appropriately for years,’ he said.
‘The fear now is the recommended changes around antipsychotics could potentially lead to deskilling, as opposed to what’s preferred, which is upskilling the workforce.
‘The most important thing is assisting the aged care facilities on how to manage patients with dementia – that’s the key. The more support that they can get, the less chance or requirement there is to turn to antipsychotic medication or any type of medication.’
To address the inappropriate use of antipsychotics, the RACGP has proposed greater funding to support geriatricians and psychiatrists, as well as GP case management, review, and supervision.
The college also supports increasing the capability of multidisciplinary teams to provide care to older people in aged care facilities.

Aged-care-RC-article-1.jpgRACGP President Dr Karen Price has come out strongly against the proposed ban.
The stance is in line with that of former RACGP President Dr Harry Nespolon. Speaking to newsGP in 2019, he said he did not believe that geriatricians need to be involved in making decisions about patients.
‘GPs can make up their minds … as to whether or not they need to call in any additional assistance, just like any other day, like any other patient,’ he said.
Dr Altaf said the uptake of such a proposal could further add to the challenge of attracting GPs to aged care.
‘It’s such a struggle to recruit and maintain GPs to work in aged care [that] I really fear changes like this are just going to put GPs off attending aged care facilities or aged care as a whole,’ he said.
‘It’s going to drive doctors out, basically.’
The RACGP has also raised concerns about the royal commission’s recommendations around a new primary care model that adds an additional layer to accreditation or credentialing requirements for GPs and practices.
While intended to support access to general practice, Dr Price says the model will only add to the barriers that aged care residents already face in receiving necessary GP care.

‘Any additional cost and administration involved in accreditation or reporting against performance measures will likely deter participation. In addition, an accreditation scheme will likely introduce barriers to GPs from non-accredited practices providing care,’ she said.
‘As the RACGP has said time and time again – proposals that increase the burden on GPs or practices, or in effect exclude most GPs or practices from providing services to older people, will lead to further reductions in access to necessary and high-quality care.
‘The recommendations do feature a boost in the Aged Care Access Incentive; however, it does come with it an increase in the number of services delivered to qualify.
‘There is a substantial amount of work that goes unremunerated, including liaising with residential aged care staff regarding medical concerns, or phoning or meeting with relatives.’
The RACGP made a number of recommendations for improvements that could be made to other areas, including:

  • improvements to technology, including digitising medication management and enhancing remote access to patient records and medication charts
  • separate Medicare item numbers for GP services provided by telehealth, allowing a nurse or other health practitioner to represent the patient
  • more opportunity for medical students and interns to provide aged care services through rotations and training placements to help address longer term medical workforce shortages
  • reinstating a model such as the Prevocational General Practice Placements Program to create a pathway into aged care work settings for junior doctors specialising in general practice
  • providing additional support for GPs performing home visits to cover the costs and time involved.
Both Dr Price and Dr Altaf say it is clear that there needs to be greater consultation with GPs on the ground.
‘The sector is riddled with barriers to residents receiving GP care and this must change, and the recommendations do little to address this,’ Dr Price said.
‘GPs are core to keeping people well and in their home, providing continuity over time, and supporting transition of care and oversight when a patient moves to residential aged care. [But] there has been a tendency to exclude the RACGP and GPs from consultation and design processes, despite proposing various initiatives which would have a significant impact on the sector.
‘GPs must be involved in reforms relating to aged care – we are an integral part of this process.’
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Dr Janice Faye Sheringham   3/03/2021 8:10:20 AM

While I understand the Commissioner’s concerns about the high usage of anti-psychotics and similar sedatives in residential care, I believe most GPs would place the cause for these drugs’ apparently excessive use on the ability of card staff, under-resourced as they are in terms of numbers, not training, to be able to spend adequate time with residents to apply both preventive and management strategies in settings where high levels of anxiety, confusion and, at time, aggression, are displayed by disturbed residents. Almost all of these residents are in need of high level personal, physical and often emotional care, which is impossible to deliver with the currently permitted staffing levels. Private providers have trimmed such staff to the bone, so that on a normal day shift, 2 or 3 personal card staff, plus 1, or at most 2 SENs and 1 RN/NUM, have to care for 30 very infirm residents! Meal times may see additional help from food service staff, but night staffing levels are abysmal!

Dr Hugh Michael Connolly   3/03/2021 10:12:42 AM

I whole heartedly agree with Dr Farringtons comments .
Staffing levels, under funding, lack of education and limited to no access to geriatricians are the main problems effecting good N/H care and the prescribing of anti psychotics a drop in the ocean albeit an "important drop "as far as I am concerned .
Any more rules and regulations like put in for the prescribing of tramal, tapentadol etc. etc .then I am out and over 60 patients will be effected
Hugh Connolly Mandurah W.A