Opinion

ECG changes the latest in a string of questionable decisions


Edwin Kruys


30/07/2020 3:45:31 PM

Dr Edwin Kruys reflects on a number of Government-mandated changes to general practice.

Pyramid of healthcare with money at the top.
Dr Edwin Kruys says the Government’s increased spending on hospitals will come at the expense of primary care.

Australia’s health system is based on a hospital-centric model. I doubt this will change anytime soon, as Government expenditure on hospitals continues to grow – at the expense of primary care.
 
The recent outrage about changes to the Medicare Benefits Schedule (MBS) is symptomatic: it looks like GPs will no longer be able to charge for electrocardiogram (ECG) item numbers that include reporting. The Department of Health (DoH) seems to believe this is a job for hospital specialists only.
 
Earlier this year, all hell broke loose after a departmental campaign targeted GPs who deliver mental health care to their patients alongside physical care. And then there was the DoH’s intimidating ‘opioid crackdown letter’ to GPs, affecting the effective delivery of palliative care.
 
The DoH continues to disrupt healthcare provision in Australia with a ‘penny wise, pound foolish’, management-by-spreadsheet approach. General practice remains largely undervalued.
 
Yet, the long-term benefits of primary care are well known. Adequate support for general practice is associated with slower growth in health expenditure and better system quality, equity and efficiency, as well as savings to the health system.
 
State hospitals are facing unsustainable cost blowouts and ever-increasing waiting lists in the face of significant population growth.
 
Increasingly, there is talk about supporting general practice to deliver more care in the community through collaborative models of care.
 
Yet the DoH believes GP should not be providing care that includes skills such as interpreting ECGs to ‘reduce low-value care’ and because it is ‘safe and best practice’. I wonder how safe the DoH’s new ruling is for patients presenting with cardiac symptoms to their GP.
 
It appears the recommendations by the 12-Lead Electrocardiogram Working Group, originally made four years ago, were reworked by DoH. The end result did not go down well at the time.
 
The RACGP responded in a submission in early 2018, stating that it ‘does not support the proposed recommendation … as it fails to recognise or acknowledge that GPs perform ECG interpretation, report results in the patient record and determine actions without referral’.
 
The feedback clearly fell on deaf ears. Stakeholder engagement by the DoH appears to be little more than a tick-the-box exercise.
 
The fact this ECG news came out of the blue and amidst a second wave of COVID-19 is awkward.
 
Effective care provided in general practice reduces the need for more expensive hospital specialist care. Health systems with a greater focus on primary care are more equitable, have lower costs and better health outcomes.
 
The poor departmental decision-making of late sadly encourages health inefficiencies and deskilling of the general practice workforce. It goes against efforts to deliver patient care closer to home. It is highly demotivating for general practice teams, especially amidst the COVID-19 pandemic, and demonstrates a concerning absence of a long-term vision.
 
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Department of Health funding general practice government Medicare



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Dr Michiel Mel   31/07/2020 7:20:45 AM

Well said Edwin! It's interesting to find out what the reasoning is of DoH. I wonder: Have there been different specialist colleges in the ear of DoH? Like in hospital the policy is "chest pain is always cardiac until proven otherwise with serial ECGs." Has there been a college may be that has found ECGs in GP are not in line with that policy? And therefore totally ignoring so many other indications for making ECGs in daily general practice.
Also an ECG machine in a practice isn't revenue producing. The device is around $3500 and the medicare rebate doesn't earn that back after depreciation, costly ECG paper, nurse usually producing the ECG, etc.


Dr Jean-Marc De Maroussem   31/07/2020 7:22:41 AM

Excellent article Edwin.


Dr Michael Lucas Bailey   31/07/2020 8:33:53 AM

As a GP I watched as we lose item numbers for things we are perfectly competent to do. We are more stringently criticised as statistical outliers. Our practice is expected to slavishly follow guidelines as if they are law. If a patient is harmed by following guidelines that’s ok. If they do well by not following guidelines then apologise to AHPRA. We were trained in evidence based medicine which was supposed to look at research rather than expert opinion. Now we are required to follow expert opinion and woe betide a GP that uses pubmed. Specialist care is now considered the gold standard but getting people into public specialists is a joke. So our skills have been reduced to sitting with our hands tied, apologising to patients that the system is broken and writing letters that will get triaged by nurses or administrators while pharmacists hand out antibiotics with so much as a urine dipstick.


Dr Peter Ryder, Torquay   31/07/2020 10:45:41 AM

They know we will continue to have to interpret ECGs in our practice - they just cynically now will pretend we dont, and not pay us for it. Are you going to wait for every stable patient presenting with AF to see a specialist in 2 months time? No - you are going to interpret the ECG and start appropriate further investigation and treatment.


A.Prof Frank Reedman Jones   31/07/2020 12:25:21 PM

Erudite as usual Edwin!
As I have publicly stated on many occasions ‘ countries with a strong primary health cafe system have better overall health outcomes’
The message is clear: policy makers and politicians have heard , but seem unwilling to action. That is where our focus should now be! Our tactic needs to change: cultural change will force structural change!


Dr Bijay Pandey   31/07/2020 12:54:40 PM

I hope department of health understands that once ECG is interpreted well, it will stop many patients going to the hospital unnecessarily.
I am afraid that a lot of GPs will be referring patients to local emergency department for the ECG assessment of any patients with chest pain or palpitation as general practice is not remunerated for the work they are trained and equipped to do.


Dr Saad Ghalib Jaber   1/08/2020 3:49:47 PM

Arguing with government is a waist of time, deaf ears. The message is clear, ECG is not for you GPs, hence, refer any chest pain to emergency department, that’s what they want. And then tomorrow they will come back and said nurses will read the ECG to triage the patients, what a humiliation to our profession, the trend is endless, unless we end it during the election time.