GPs need more backing to improve aged care: RACGP President

Matt Woodley

19/02/2019 2:49:23 PM

Dr Harry Nespolon has told the royal commission that GPs don’t receive enough support when treating patients in aged care facilities.

Aged care could be improved by giving more support to GPs
Aged care could be improved by giving more support to GPs

RACGP President Dr Nespolon also stated inadequate remuneration, communication breakdowns and a lack of physical infrastructure in residential aged care facilities (RACFs) are further barriers to GPs providing onsite care, when he spoke at the Royal Commission into Aged Care Quality and Safety.
‘There is a progressive decrease in the number of GPs who are willing to work or go and see patients in nursing homes,’ Dr Nespolon said.
To support his position, Dr Nespolon presented excerpts from a blog that describes two weeks in the life of a GP who previously provided care to patients at RACFs, but was compelled to stop due to the unsustainable nature of the work.

The blog, written by Canberra GP Dr Thinus van Rensburg, lists issues including unpaid travel time, note making and consultations, problems communicating with staff at under-resourced RACFs, and a lack of nurses on site after hours as the reasons why he decided to stop treating lifelong patients.

‘There is a lot of non-face-to-face work that is involved which there is no rebate for,’ Dr Nespolon explained.

‘What you don’t see is the time out of practice. A lot of these consultations are done out of hours because it’s the only way it makes any economic sense, because if you leave your practice during the day you’re not seeing patients that you would normally see.

‘It also underlines the poor staff handover – instructions not to send people to hospital or instructions to call the doctor are often ignored, and I should have added earlier on, this is quite a common story.’
As a result, Dr Nespolon said GPs often become the default for all the inefficiencies of the system.
‘Whatever needs to be done, the GP is meant to do it and they really can’t just say, “Well, I’m not going to do it” because the patient needs that care,’ he said.
‘What this case doesn’t illustrate is the lack of physical infrastructure which is often found within a nursing home to assist the GP in providing better care for their patients.
‘This is all underlined by general practices de-funding over the last five years. It makes the time spent out of your practice dealing with nursing home visits so much more relatively expensive than they have been in the past.’
Dr Nespolon said this lack of funding is leading to a system in which a single GP assumes the care for all patients within RACFs, meaning new patients often see a different GP during what is a ‘very traumatic’ time in their life.
‘As the relative funding drops it means that people need to use different models of providing that care, and one of the efficient ways of doing that is to see more patients in a single visit,’ Dr Nespolon said.
‘It does lead to some specialisation of care of elderly patients, but the college would still say that we should be encouraging GPs to take care of their patient all the way through their lives.’
The commissioner also raised the supposedly high use of chemical restraints within RACFS; however, Dr Nespolon said he believed this had been overstated and, while not ideal, is often necessary for the safety of other patients and staff members. He also said further regulation is not the solution.
‘It doesn’t take into account the thousands of different situations and contexts that people find themselves in. There are so many factors that are involved in this, and sometimes you’ve just got to trust the medical staff and the nursing staff to do the right thing,’ he said.
‘I would suggest that most of my colleagues are doing the best for their patients. They’re trying to decrease the amount of medication, they’re trying to keep them as comfortable as they possibly can and that can be really difficult at times.’
Dr Nespolon added that increased funding, improved records management – something he believed My Health Record would assist with – higher RACF nursing staff levels and regular use of intake assessments would lead to better long-term care for patients.
‘It is a virtuous circle – if there is that support you will find that there are more GPs doing nursing home work, and … I would like to hope that the care that the patient gets is much better and the experience of the staff within a nursing home is actually better,’ he said.
‘Rather than sort of running from one patient to the next, they’re actually providing care for that patient.’
The royal commission will provide its interim report by 31 October, with the final report due no later than 30 April 2020.

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Dr Peter Robert Bradley   19/02/2019 3:55:18 PM

[‘There is a lot of non-face-to-face work that is involved which there is no rebate for,’ Dr Nespolon explained.]

Every time this statement is heard, it is describing the reason why the fee for service model no longer can cope with this type of care, and the been for bulk funding in some shape or form. The problem is how to do that in any way that's fair to both practice and the provider doing the work. This problem, in my view, is best solved by a global salary for a global job, rather than trying to create a fair system out of a blended system of capitation and fee for service, with all the issues that also faces in trying to achieve the best outcomes in a fair way. Having recently retired, I have to say, nothing in over 40 years in GP has caused me to change that view.
I also would like to add, I find these pathetic security things to try and prove I am not a robot intensely irritating. Especially since it often asks again for a valid security code, when I just did already.

Dr Ian Light   20/02/2019 9:31:10 AM

The problem is empathy skilland time to prevent and treat ill health and ill treatment .
A great help was the general practitioner able to call in very skilled teams from hospital eg the Alfred Hospital Melbourne to help doctors with clinical history and exam and take blood tests and samples .
My belief is that in certain areas probably wealthier areas these skilled and empathetic teams readily available but in less wealthy peripheral areas this "virtuous circle " is severely disrupted .
Study Courses in aged care for the Health Professional Teams and Caring and Knowlegable Family and Volunteers Trained in Scenario Exercises need implementation.
Diplomas in aged care with research feedback for beneficial outcomes ought increase .

Tony Bowden   20/02/2019 1:34:45 PM

There is an opportunity to change the manner of health maintenance in aged care. Effective use of interns with funding through hospital geriatric terms or GP terms could provide continuity of care, support of GP input , support and team cohesion with already challenged nursing staff and a valuable learning term for interns.
It would require a team mentality approach from aged care providers and health delivery practitioners as well as sensible funding from the government. Aged care is looming larger as a cost is but this would be a practical and achievable model and a good use of health dollars and with measurable outcomes.
Too many ideas have been floated that only shift health dollars and don’t address health issue.
Maybe the RACGP could review this idea rather than trying to sort the benefit of my heath homes and my health record.
It could overcome the declining GP numbers.
Despite the blessings of health ministers care of GPS has never declined despite the non financial input

A.Prof Christopher David Hogan   20/02/2019 5:08:10 PM

As a young GP I was told that the care of society's failures falls upon teachers, police & GPs. Nothing I have seen in 44 years of being a doctor makes me think any differently