Public servant asks surgeons to ‘say no’ to GPs

Matt Woodley

1/10/2020 3:38:38 PM

A program manager has suggested surgeons refuse GP referrals for ‘old’ patients or those with comorbidities, drawing a strong GP rebuke.

Surgeon reaching for surgical instrument
Surgeons were asked to ‘say no’ to GPs who had referred elderly patients or those with comorbidities for surgery.

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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Dr James Courts   2/10/2020 7:31:11 AM

I think you'll find the cost of an ED visit is a whole lot more than $250.

Dr Igor Andrew Jakubowicz   2/10/2020 7:51:36 AM

With the demise of the Divisions of General Practice, it seems the Health Networks are now just government run organisations with little regard to, or respect for, doctors in general and GPs in particular, paying only lip service where money can be saved.

Dr Phillip Charles Harvey   2/10/2020 8:45:30 AM

I think there is a valid issue here - some surgery may be inappropriate for the very elderly. That should be discussed with the patient, their family and maybe in consultation with the GP.
But I find it strange that the Program Manager puts it in terms of the surgeon saying ‘no’ to the GP. They should accept the referral and then make a clinical decision, either for surgical or non-surgical management.

Dr Philip Ian Dawson   2/10/2020 8:57:52 AM

GPs are not referring patients to a surgeon for an operation, they are referring for a specialist opinion. If the surgeons opinion is an operation is inappropriate they will write that in a letter to the referring GP. Is the public servant suggesting GPs managing complex and sometimes difficult patients are not entitled to a specialist opinion on the case? There are other things a surgeon may suggest for management other than just an operation, They may suggest further investigation, eg MRI, which is not rebateable for many things if a GP orders it but is Medicare rebateable if a specialist orders it. They may suggest other treatments. Whatever the case if a GP is having difficulty managing a patient, whatever their age or comorbidities, they are entitled to get a specialist opinion from the specialty they consider most appropriate. Without the need for an opinion from a medically untrained public servant.

Dr Graham James Lovell   2/10/2020 9:20:09 AM

Fascinating that public servant criticises GPs for poor referral data, when a few weeks ago I took the Flinders Medical Centre Gastroenterology registrar to task about the lack of a template for referrals. His response in regards to the 7000/year was that he had done one and SA Health had incompetently lost it ,so he refused my request to recreate it. This is the stupidity that we face every day dealing with our health system bureaucracy!
Oh and he stated level 1 priority for scopes is for under 1 year, level 2 =2 to 3 years, and level 3 would make Mandy Nolan happy as he stated that’s currently over 5 years...

Dr Henry Arthur Berenson   2/10/2020 10:48:23 AM

The real problem is that GPs accept specialists triaging referrals. In Canberra, some psychiatrists are refusing to see ADD patients, effectively discriminating on the basis of mental illness. If they cannot act as consultants, they do not deserve accreditation.

Dr Peter James Strickland   2/10/2020 12:17:23 PM

There is no doubt in my mind that Mandy Nolan needs to be either sacked or moved out of any responsible position. It is outrageous and unethical to refuse treatment for anyone requesting it, and especially when that elderly patient may be requesting the surgery for very good reasons, e.g looking after a demented or disabled wife or husband, to continue to be able to travel to see relatives etc etc. This is an example of public servants interfering in the care of patients, and only worrying about "dollars" --- it is time for her to go, and anyone who agrees with her suggestion. There should be no ifs or buts ---- out of her role now! What about surgery for severely disabled younger people who have paresis, or serious heart problems, or diagnosed with cancer who need painful secondaries treated etc --- the suggestion by this public servant needs to be understood for what it is, and found to be totally unacceptable to everyone in a civilised and caring society.

Dr Steve Hambleton   2/10/2020 1:25:13 PM

How about we put the local hospital specialists and the local GPs and some consumer reps in a room (could be virtual) to work up a model of care that works for both that is tailored to their local resources and needs. Referral with refusal and which is what the GP sees and flooded by GP referrals which is what the specialist sees and a disconnected health system which is what the patient sees is clear not working for the doctors or their patients.

Dr Chien-Che Lin, Palliative Medicine Specialist and General Practitioner   3/10/2020 8:30:57 AM

The patients and their families are entitled and will certainly seek a second opinion directly from a surgeon if they didn't believe their GP. The government can decide how they want to pay for it: an elective consultation with the surgeon; an unplanned Emergency visit that will still turn into an outpatient consultation with the surgeon; or they might not want to pay for it at all and the patients who can afford to will end up paying the private health insurances and private surgeons while the patients who can't afford it will suffer inequity.

Dr Everest Osondu Nkire   4/10/2020 1:32:55 AM

This is sadly bringing to the fore the broad issue of GP referrals to the hospitals and refusals by these mostly civil servants placed in triaging positions based on unilateral templates prepared by these hospitals without input or consultation of GPs on the preparation. Most of these hospitals do not understand how GPs work or function and demand referral guidelines which may be impossible for the GP to fulfill. Some even demand investigations which are not rebatable to the patient when referred by the GP and other information which may not have any influence on the patients management. These public hospitals need to consult and engage GPs in their local area while preparing these guidelines and also incorporate the GPs own views before adopting these. This will save the patients the extended long waiting times and often times denial of services to deserving patients whose referrals from GPs are refused on unilateral unfounded grounds.

Dr Rodney Paul Jones   4/10/2020 3:32:49 PM

When I see that phrase "not in their best interest" a cold hand grips my heart. I wonder exactly whose best interests they are talking about. It's a Red Light warning for "Denial of Service "about to happen for a reversible treatable condition because they are somehow deemed not worth the trouble.

Dr Maureen Anne Howard   4/10/2020 6:12:00 PM

So Mandy Nolan is referring to elderly patients as 'rubbish' ! With that attitude, what further comment is required?

Dr Michiel Mel   10/10/2020 7:36:16 AM

Apart from taking Nola's message as an insult, it would be prudent to identify where her thoughts have come from. Has SA health got a budget problem like most have. And is such a poor placed cut corner a way to address this? And it leaves me wondering why it is so hard for our bureaucracy to have a meaningful discussion on how to get referral processes and correspondence back to GP improved.