Public servant asks surgeons to ‘say no’ to GPs

The requests, made over the weekend in leaked emails obtained by the ABC, argue that health services need to ‘tighten up our processes with regards to incoming referrals’ from GPs.
 
Central Adelaide Local Health Network (CALHN) Acting Surgery Program Delivery Manager Mandy Nolan emailed surgeons on Saturday to suggest they ‘say no’ to GPs referring older patients or those with comorbidities for surgery.
 
‘We also expect that where the person is old or has many comorbidities, you might suggest to the GP that is not necessarily in their best interests,’ the email reads.
 
‘Please use your wealth of consultant experience and start to say “no” when clearly not sensible and high value care.’
 
Acting RACGP President Associate Professor Ayman Shenouda said GPs are more than capable of managing the care of older patients, particularly those with complex comorbidities, and added it is highly inappropriate for public servants with no clinical experience to second-guess primary care professionals.
 
‘GPs have the skills and knowledge to analyse and manage the vast majority of conditions our patients face. We do this every day,’ he told newsGP.
 
‘Having worked in aged care for many years, I know how complex and difficult some of these decisions can be. But I also know no one is better placed to help patients navigate their own healthcare than their long-term family doctor.
 
‘We know our patients better than any other health professional and should be trusted to help them make choices that represent the high-quality care Australians expect from their GP.’
 
Professor Dimity Pond, a GP with a special interest in aged care, described Ms Nolan’s comments as ‘unbelievable’ and said they undermine GPs’ clinical expertise, as well as the way they manage their patients.
 
‘She’s not just second-guessing the work of GPs; she’s also giving instructions to surgeons about their triaging of patients. And that’s inappropriate,’ Professor Pond told newsGP.
 
‘It’s up to the surgeon to choose people who are appropriate for surgery. It’s actually not up to the GPs themselves, nor is it up to a public servant to make that call.
 
‘I would add that with advances in surgical techniques, many older people can have very successful surgeries with a huge improvement in their quality of life.’
 
The email also prompted outrage from the South Australian Salaried Medical Officers Association (SASMOA), whose President Dr David Pope told the ABC it is ‘unethical’ for a person in an administrative management position to make suggestions about clinical care.
 
In a subsequent email sent the following day, Ms Nolan wrote that she did not want to cause offence and said the surgical leadership team is ‘extremely patient centric’.
 
She also indicated that Adelaide’s central public health network does not have sufficient resources and that patients are ‘deteriorating’ because they are not getting the care they need.
 
‘Our network is significantly and overwhelmingly over CAP which means we [sic] caring for more patients than we have the resources to treat,’ the Sunday email reads.
 
‘Due to this, a great proportion of our wait lists are long and the patients are deteriorating and they potentially could have been somewhere else, sooner.
 
‘I agree that all referrals have a patient suffering in some way at the end and we are trying to get patients that need us the most quickly, and providing other options for those while they are waiting.’
 
In addition to criticising the appropriateness of some GPs’ surgical referrals, Ms Nolan also questioned their quality.
 
‘We expect that many referrals might need to be returned to GPs as they will be insufficiently complete for safe and accurate triage,’ she wrote.
 
‘When we accept rubbish, we will get more of it.’
 
However, Professor Pond said this demonstrates a fundamental misunderstanding of how the system works.
 
‘GPs who refer people to a surgeon are expecting that the surgeon will examine that person and triage them appropriately,’ she said.
 
‘We will, of course, give appropriate history and medication, but we are not triaging people. That is that is something that we gladly hand over to our surgical colleagues to make that call.’


Acting RACGP President Associate Professor Ayman Shenouda said it is highly inappropriate for public servants with no clinical experience to second-guess GPs.

Professor Pond also said the overall sentiment of Ms Nolan’s comments are ‘appallingly ageist’ and show a lack of respect for the surgeons whose job it is to assess whether a procedure should go ahead.
 
‘It seems that this person assumes it’s not worth trying to treat old people,’ she said. ‘That is totally unacceptable in this day and age. We should not be having ageist decisions made.
 
‘[The emails are] full of stereotypes. She’s got this idea that the surgeons are wasting money treating a whole lot of “poor old dears” when in fact that’s far from the case. Most surgeons … want to treat someone that’s going to get better.
 
‘Of course, if a GP refers someone to a surgeon and that patient isn’t likely to benefit from the surgery, I would anticipate that the surgeon will say no … [but] they have mechanisms for determining whether surgery is appropriate. They have outcomes data that people look at.
 
‘We don’t tend to send people to a surgeon if we don’t think they will benefit from surgery. Or we may want a surgical opinion, and that’s entirely appropriate.
 
‘But a GP who’s been in practice for a few years is well aware of who’s going to benefit from surgery and who is too sick to do so.’
 
Associate Professor Shenouda said if SA Health is struggling to provide enough resources to meet patient demand in its hospital wards, the State Government should consider investing more in primary care.
 
‘General practice is the cornerstone of Australia’s healthcare system. It is also the most cost-effective part of our healthcare system, but unfortunately it continues to be taken for granted by governments,’ he said.
 
‘The RACGP has been working for years to increase the access to and affordability of general practice for Australian patients in order to avoid overcrowding and long wait lists in our expensive hospital system.
 
‘Unfortunately, pointing out that the typical $37.60 Medicare rebate is dwarfed by the average $250 spend on each visit to the ED doesn’t attract the same headlines as a multimillion dollar hospital upgrade.’
 
According to the ABC, SA Health did not provide a response when asked whether it is appropriate for administrative staff to be making suggestions about referral management and patient care.
 
But in a statement to ABC News on behalf of SA Health, CALHN Medical Lead for Surgery Professor Jane Andrews said hospitals and GPs are collaborating to improve services for patients.
 
‘We are implementing a number of solutions to improve wait times and through collaborative work with our GP colleagues,’ Professor Andrews said.
 
‘Referrals from GPs, who know their patients best, need to include sufficient information so our specialists can accurately triage consumers to ensure no-one is left without advice or care.
 
‘Our recently appointed GP liaison doctor is working with us and her GP colleagues to improve two-way communication to ensure our community can access the best and fastest route to care.’
 
Along with a larger investment in primary care, Associate Professor Shenouda suggests greater collaboration between medical teams would result in a more patient-centred model.
 
‘Making complex decision related to medication, surgical intervention, rehabilitation and functionality, combined with broader family decision-making requirements, needs a really good team,’ he said.
 
‘These teams should be supported by a financial model that can allocate time for multidisciplinary case conferences.’
 
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