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General practice takes centre stage at aged care royal commission

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Witnesses in the latest round of hearings have told the Royal Commission into Aged Care Quality and Safety that while many GPs are providing excellent care, the current system has ‘broken down’ in numerous instances, as fee-for-service does not encourage holistic care or continuity of care.
 
The succession of horror stories that have punctuated proceedings – most recently an elderly patient who received only Panadol after complaining of chest pains for four days and was later found to have suffered a heart attack – have led to calls for reforming fee for service under the Medicare Benefits Schedule (MBS).
 
Dr Paresh Dawda, a director at Prestantia Health, which provides primary care services exclusively to people living in residential aged care facilities (RACFs), told the royal commission that while the current fee-for-service model helps improve access to care, it also hinders appropriateness of care, team-based care, and innovation in service delivery.
 
But he also said that while capitation has some of those advantages, it comes with the potential risk of under-servicing.
 
‘There’s no payment model that’s, on its own, truly fit for purpose,’ he said. ‘Therefore, a blended payment model which makes [the] most of the advantages of the different models and tries to minimise the disadvantages is perhaps the way to go.
 
‘When I look at the complexity of care that’s required within residential aged care – the need for team-based care, the need for prevention, the need for comprehensive care, the need for coordination – there’s no doubt in my mind that a blended funding model is the fit-for-purpose funding model that can help deliver some of those requirements where we need them in aged care.’
 
The royal commission is currently investigating blended payment arrangements that potentially involve a general practice treating an aged care recipient, or a group of them.
 
The proposed system would see practices receive an annual payment based on the recipient’s or the group’s health needs, coupled with fee-for-service payments for complex or after-hours attendances.
 
The royal commission also heard testimony from GP and aged care consultant Dr Troye Wallett, who provided recent market research on more than 100 RACFs that showed more than half had an ‘immediate need’ (as soon as possible) for a GP to attend, and just less than half had an ‘urgent need’ (that day).
 
The lack of access to GPs at some RACFs was apparent in the testimony of Rhonda McIntosh, whose father Allan Sheldon experienced a heart attack over four days without treatment, as his claims of chest pain were dismissed as ‘paranoia’.
 
Ms McIntosh told the commission a GP would only visit the RACF in question once a week, and that even then there was no guarantee every patient on the day’s list would be seen.
 
‘It shouldn’t be a once-a-week thing,’ she said. ‘You should be able to access a GP when you’re sick or when you need to, or when you feel that you want to … he shouldn’t have to beg staff for it or he shouldn’t have to wait until we’re able to advocate for him.’
 
Having been told by staff an ambulance ‘would not come’ if called, it was not until Ms McIntosh took her father to an off-site GP that he was taken to hospital via ambulance and had a stent inserted into his heart.
 
The royal commission heard 46% of GPs are not delivering any services to aged care residents, while 8% of permanent RACF residents did not see a GP over a 12-month period, compared with 2% of home care recipients.
 
Dr Wallett said he believes a lack of remuneration is the largest barrier for attracting more GPs to work in RACFs.
 
‘The MBS structures don’t make provision for working in aged care facilities,’ he said.
 
‘They do slightly, but often it feels like the item numbers are wedged into aged care, and they are difficult to make sense of and understand what you are able to bill for and what you’re not able to bill for.
 
‘The other thing that MBS does at the moment with all the item numbers is it incentivises acute care over proactive care … [so] having [a system with] more provision for proactive care is very important.’
 
However, Professor Dawda said that while he believes remuneration is part of the issue, there are other factors related to ‘professional satisfaction’ that have stopped more GPs working in RACFs.
 
‘What puts people off … is the huge volume of non-clinical administrative tasks – faxes toing and froing, messages sort of bouncing around,’ he said.
 
‘If some of that non-clinical burden can be systemised and made more efficient and made to be less of a burden, then I think that would incentivise some GPs to do aged care.’
 
GP and current AMA President Dr Anthony Bartone supported this assessment. He said more needs to be done to fund the time spent by doctors that does not involve face-to-face contact with patients.
 
‘Non-contact time with patients, essentially, except very few occasions perhaps, is not remunerated,’ he said.
 
‘What we’re seeing now is an increased movement or an increased understanding that fee-for-service alone will not support the increase in chronicity of care, the increased complexity of care and the increase in non-face-to-face care.
 
‘That increasing non-face-to-face component needs to be funded in an alternative way.’
 
Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told the commission while the system is in need of reform, the College would not be in favour of a ‘pay for performance or strict outcome-based pay’.
 
‘[Such a system] distorts clinical decision-making and leads to a number of unintended consequences,’ he said.
 
‘The College is supportive of schemes that encourage quality improvement. So that’s a subtle difference from outcomes-based pay.
 
‘It’s about improving from where the situation is now and becoming a learning organisation to move on and get better, rather than reaching some threshold to achieve some payment.’
 
Other topics covered:

• GPs should attend aged care facilities as part of their training
• The challenges GPs face caring for RACF residents when specialist input is required
• Whether nurse practitioners should be involved in comprehensive health assessments
• The lack of RACFs using My Health Record and other digital communication
• The introduction of telehealth item numbers for aged care residents
• Improving facilities at RACFs to aid the work of GPs and other health practitioners

The current round of hearings is set to run until 13 December, and will continue to focus on interfaces between the aged care and healthcare system.
 
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aged care MBS residential aged care facilities Royal Commission

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