‘Groundhog Day’ as GPs again overlooked in aged care COVID report

Matt Woodley

2/10/2020 4:44:41 PM

Despite providing the majority of medical care in residential facilities, the aged care royal commission has failed to recognise GPs.

Lonely older man
The Acting RACGP President has said GPs ‘will be essential to any efforts aimed at improving patient outcomes and pandemic preparedness’ for aged care.

The Royal Commission into Aged Care Quality and Safety’s special report into COVID-19 reveals Federal Government preparations were ‘insufficient’ to ensure the sector was fully prepared for the coronavirus pandemic, and makes six recommendations to safeguard against future outbreaks.
These include the creation of a national aged care advisory body and plan for COVID-19; a requirement for all residential aged care facilities (RACFs) to have one or more trained infection control officers as a condition of accreditation; and the establishment of Medicare Benefits Schedule (MBS) items to increase the provision of allied health services.
Acting RACGP President Associate Professor Ayman Shenouda has welcomed the commitment to a comprehensive COVID plan and national aged care advisory body, but said GPs must be involved or the sector risks repeating the mistakes of the past.
‘As the main coordinators of care for residents in aged care facilities, GPs will be essential to any efforts aimed at improving patient outcomes and pandemic preparedness,’ he told newsGP.
‘Unfortunately, the royal commission’s special report appears to have ignored this central role in the provision of care, and I would urge the Government to rectify this oversight when putting together the national aged care advisory body.
‘There have been more than 20 reviews into aged care in the past 20 years, yet limited progress has been made. I fear unless the expertise and insights of general practice are relied on more, this cycle of structural neglect and dysfunction will continue.’
The other recommendations included in the report, all of which have been accepted by the Federal Government, are to ‘immediately’ assist providers that apply for funding to ensure there are adequate staff available to allow continued visits to people living in RACFs; arrange with the state and territories to deploy accredited infection prevention and control experts into RACFs; and to provide Parliament a progress report on the implementation of the recommendations by 1 December.
However, despite the report being presented as an ‘investigation into the response to COVID-19 in aged care’ and offering potential solutions to improve the sector’s overall response to the pandemic, general practice is not referenced once in the 30-page, 12,000 word document.
GP and lecturer with a special interest in aged care Dr Ken McCroary told newsGP the exclusion of general practice feels like ‘Groundhog Day’ and represents a wasted opportunity.
‘Once again the so-called experts have completely ignored the actuality that the vast majority of all medical care in RACFs is performed by GPs,’ he said.
‘They call in “experts” to these commissions who have less expertise in caring for people in RACFs than GPs do, because they don’t do it.
‘How does that make any logical sense?’

Dr McCroary also criticised the disparate rebates awarded to GPs in comparison to specialist geriatricians, and called for more overall funding to help support aged care.
‘We look after our aged care patients to the best of our ability using an underfunded model,’ he said. ‘Yet geriatricians get a Medicare rebate more than double that of GPs for the same visit, with the same outcomes.
‘We’re not really funded for much of the work we do, such as mental health care. It’s extra time we dedicate essentially voluntarily.’

General practice appears to have once again been shut out of aged care planning. (Image: AAP)

While supportive of more funding for nurses and allied health professionals, Dr McCroary is disappointed at that minimum staffing ratios at private RACFs will not be implemented.
‘It was a missed opportunity to ensure improvement in quality healthcare for the residents in our RACFs. Mandating a ratio of registered nurses is a must going forward,’ he said.
‘You could equate non-nurse staff being left in charge of medical care to the untrained security guards being put in charge of Melbourne quarantine, as opposed to trained expert ADF personnel.
‘The difference in likely outcomes and the potential for disaster is the same when we don’t have registered nurses helping us look after these incredibly vulnerable residents.
‘From someone who’s on the ground, it makes a massive difference trying to care for someone if I’ve got experienced registered nurses looking after the residents.’
Similarly, Federal Secretary for the Australian Nursing and Midwifery Federation (ANMF) Annie Butler welcomed aspects of the report, but said it failed to address core staffing problems related to dangerously inadequate levels of qualified nurses and care staff.
‘[RACFs] desperately need additional nurses and care staff to provide safe, effective care outcomes for residents, not just to enable more visitors,’ Ms Butler said.
‘While that is critical for the wellbeing of residents, more staff are urgently needed just to meet basic needs for residents in far too many nursing homes.
‘Our members have been on the frontline during the pandemic and have witnessed how it has stretched staff and resources even further, again demonstrating the importance of having sufficient staffing levels and skills mix to cope with intensified demands and workloads.
‘In Victoria, where privately-run nursing homes set their own staff ratios, there [have] been more deaths and higher rates of COVID-19 than in Government facilities, which have mandated minimum staffing levels, including registered nurses on every shift.’
Another area of aged care reform previously highlighted by the RACGP, but not acted upon by the commissioners, is the need to better facilitate and measure the delivery of telehealth from GPs to RACF residents.
Associate Professor Shenouda said supporting continued GP access to people in RACFs, both through expanded telehealth and more general supports, will be vital for the success of any COVID plan.
‘MBS items have been created to support telehealth services and eliminate the risk posed by face-to-face contact during the pandemic. Unfortunately, no equivalent telehealth items were introduced for GP attendances at RACFs,’ he said.
‘GPs are already conducting consultations with patients in RACFs via telehealth, but it is not possible to understand the volume of care these GPs have provided during the pandemic without specific telehealth item numbers for consultations.
‘There is also a lack of equivalent telehealth items for health assessments for permanent residents of RACFs similar to those for geriatricians, nor are there any telehealth items for GPs to provide medication reviews.
‘The expansion and retention of these proposed telehealth items should extend beyond the COVID-19 pandemic, without area restrictions.’
The royal commission is expected to deliver findings from its wider inquiry into the aged care sector on 26 February 2021.
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Dr Chien-Che Lin, Palliative Medicine Specialist and General Practitioner   3/10/2020 8:06:54 AM

Every medical specialty need to work together to restore the respect and expectation of specialist GP participation in long term medical care of everyone in the community. One of the first steps is to stop using Nurse Practitioners as replacement GPs, and continue to focus on Nurse Practitioners as extensions of specialist hospital services with mandatory GP participation on the front line.

Dr Julie Anne Copeman   3/10/2020 10:00:59 AM

I find it most interesting that the current trend I’ve noted is to delegate basic work back to the GP eg initial script for dementia medication as if we are lackeys . I find this disrespectful. The last geriatric hospital review feedback listed all the tasks needing to be done - either the dementia patients husband or I were to organise them all - I remain unsure what the entire hospital team were doing to justify their existence. To be totally ignored in an Aged Care review in this way is a breathtaking insult.

Dr Peter James Strickland   3/10/2020 10:29:54 AM

The Federal Govt has ignored the important role of GPs in Aged care for as long ago as 50 years. The only concern by all governments was the cost of GPs visiting their patients in Nursing Homes, and not the actual effort required by the GP to do so. How often I personally did prescriptions for patients in Aged care after a phone call from a Nursing Home would be several thousand, and at no remuneration. When I visited a Nursing Home to consult or review patients I was paid a pittance. No wonder there is no respect for Medicare public servants who sit in offices totally unaware of the work, travel and often inconvenience (out of hours) to visit NH patients without a respected remuneration! The RACGP and AMA have been weak on this matter all along, and it needs changing.

Dr Graham James Lovell   3/10/2020 2:06:38 PM

Everyone- the Politicians,the Health Department Bureaucrats and ESPECIALLY the RACGP are in extreme DENIAL.
The end of GPs providing the majority of medical services is happening as we write ,
and it’s progressing and irretrievable.
Firstly as it’s grossly underfunded versus consulting room work as it’s all bulkbilled,there’s inefficiencies from movement within the facility to get to patients,and more time liaising with nursing staff and relatives .Also as the average level of multiple comorbidities is extremely high (last admission on 31 tablets) we get financially disadvantaged via Medicare the longer we spend on average with a patient.
Secondly the usual GP taking on a number of RACF patient is a financially secure near retirement GP, who (A) won’t be there much longer & (B) like myself and several other colleagues will readily leave unsafe, unsupportive RACFs when the frustration gets too high.
Lastly, the majority of younger GPs are female, Who infrequently visit RACFs

Dr Elizabeth Anne Martin   5/10/2020 7:14:50 PM

As a female GP I used to see a cohort of 12 patients or so at one RACF weekly. I continued this whilst on maternity leave with my three sons. RACF work lends itself well to a breastfeeding mother and the patients loved me bringing in my babies. However, the model of care became so frustrating that I deliberately disengaged from it. Being effectively on call 24 hours, the poor remuneration, lack of consistent staffing, being called about trivial things like writing up charts for Panadol, and especially being sidelined by relatives and agency staff with resultant detrimental outcomes to the patient, all frustrated me; I didn't want to be complicit in such a broken system anymore.