GPs step up to avoid ‘absolute collapse’ of health system

High vaccine uptake was anticipated to protect vulnerable Australians and the nation’s health systems from buckling under the pressure of COVID-19 hospitalisations.
 
And while the strategy has minimised the damage, the highly transmissible Omicron resulted in a case surge unlike anything Australia had experienced previously.
 
Preparation for the anticipated demand in Victoria started with the suspension of category two and three elective surgery in early January, closely followed by the implementation of a coordinated Pandemic Code Brown across all public metropolitan and major regional hospitals.
 
As a result, primary care providers have had to step up to take the pressure off both emergency services and secondary care.
 
RACGP Victoria Chair Dr Anita Muñoz told newsGP she has seen this firsthand at her own practice, with patients who have had procedures either delayed or cancelled, adding to the ‘bottlenecking’ that has been seen across general practice for months.
 
‘General practice is treating COVID-positive patients, we’re continuing with vaccine boosters and childhood vaccines, and there is a very big backlog of undertreated people from the last two years that are now coming forth to have their conditions treated – and then we’ve also got patients whose hospital level treatment has been stalled and delayed,’ she said.
 
‘It’s a really big bottleneck and one of the key considerations for GPs and their clinics is triaging; so trying to strike a balance whereby people who are sick and at risk of deterioration can access treatments to try and mitigate that, but at the same time getting through all of those other very important services that we need to.
 
‘It’s not an easy task.’
 
The impact has been variable, with services in some parts of the state affected more than others, but a practically non-existent surge workforce capacity in rural and remote services is having significant repercussions.
 
Exacerbating the situation is a metropolitan hospital strategy to recall junior medical staff, which has increased their surge capacity at the expensive of rural services.
 
‘And, of course, because GPs often work in hospitals as well as general practice in the country, if you have to utilise the general practice workforce to do more hours in ED or on the wards, that by definition means there are fewer hours that that GP will do in clinic,’ Dr Muñoz said.
 
‘[So] patients have fewer appointments to access.’
 
Dr Yousuf Ahmad, who practises in the eastern Victorian town of Sale, is witnessing this reality unfold.
 
The Victorian representative of the RACGP Rural Council told newsGP staff are being deployed to major regional hospitals to care for COVID-positive patients, impacting capacity in the local hospitals.
 
‘This means, of course, they are then accessing general practice, which is already under significant burden because of COVID, as well as delayed presentation in general,’ Dr Ahmad said.


RACGP Victoria Chair Dr Anita Muñoz says there would be ‘utter medical chaos’ across the state if GPs hadn’t stepped up. 

Having spoken to his secondary and primary care colleagues, he says the general sentiment is that Code Brown has been a ‘double edged sword’, as making more staff available for the acute care of COVID patients has ‘created more problems’.
 
‘Rural and regional areas are always having staffing issues … and now people are leaving the system and it is putting more pressure on the staff who are left behind,’ he said.
 
‘Then the recent COVID wave has led to the situation where sometimes up to a third of the staff in acute services, as in general practice, have been off work for seven days or more.
 
‘So it’s quite a complicated situation.’
 
Dr Muñoz agrees, and says furloughing of staff has been the ‘biggest part of the crisis’.
 
‘It’s not really so much an issue of too many patients to treat, it’s more an issue of too few practitioners to keep the health services ticking over because they’re either sick or they’re furloughed due to contact,’ she said.
 
Dr Ahmad says general practice has a positive partnership with the local hospital in his area and the two services have developed their own COVID Positive Pathways, which has been supported by retired GPs re-joining the hospital workforce and junior GPs covering shifts in ED.
 
‘But keep in mind that all those GPs are still doing their normal full-time jobs without any break for the last two years,’ Dr Ahmad said.
 
‘Again, it’s not just about general practice, but I think from our perspective on the primary healthcare level, we are under a lot of stress and now we are having some responsibility of secondary care as well, which is an extra burden.’
 
In response to declining COVID-19 hospitalisation rates, on Monday elective surgery resumed at 50% capacity in private hospitals and day procedure centres as part of a staged plan.
 
If the case load remains low, Code Brown is expected to last 4–6 weeks in total. However, Dr Ahmad fears the impact on the health system, particularly in rural and regional parts, will be felt well beyond that.
 
‘We’re hearing from the staff that their morale, their capacity, their energy has been affected for two years now, but that this is probably the last straw,’ he said.
 
‘So the concern which we have is actually the long-term impact on regional and rural services, and the retention of the staff because once people move out to the city, it’s very hard to get them back.’
 
Where to from here?
What the pandemic has highlighted, according to Dr Ahmad, is a lack of health planning and collaboration between primary and secondary care, citing the COVID Positive Pathways as a prime example.
 
‘The state has developed regional public health units and they’re working fairly independently, but they have actually no working relationship with general practice,’ he said.
 
‘[This is despite] 80% of COVID-positive patients actually being managed in general practice.
 
‘That is, to me, an area where there is a great opportunity where both aspects of healthcare can work collaboratively to reduce pressure on each side and have better partnerships.
 
‘That should be the learning out of this pandemic.’
 
Acknowledging this, RACGP Victoria has been working to do exactly that. Just last week, the State Government agreed to fund urgent care centres, which will be GP-led and run to reserve EDs for emergencies.
 
‘That idea was specifically called for by RACGP Victoria,’ Dr Muñoz said. ‘So we’re really trying to work on innovative ways to make our health system operate as rationally as possible.’ 
 
The faculty is also running a series of webinars each Thursday to keep GPs up to date with developments on Code Brown.
 
Meanwhile, at a national level, the college is continuing to campaign for further investment into telehealth and item numbers for longer consultations, and to reward GPs who are managing complex and chronic disease.
 
‘I know we say this all the time, but if primary care wasn’t stepping up – and really to an unprecedented degree – we really would see an absolute collapse of health,’ Dr Muñoz said.
 
‘It is the ultimate stopgap, and I hope that by being recognised as such that funding will flow because if general practice wasn’t doing what it was doing there really would be utter medical chaos in the community.’
 
The next RACGP webinar ‘Code brown for general practice – Rural response to the Code Brown Webinar’ will take place on Thursday 10 February from 6.00–7.00 pm AEDT.
 
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