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Royal commission calls for revamped primary care funding model


Matt Woodley


1/03/2021 5:48:58 PM

The recommendation was contained in the newly-released Final Report from the Royal Commission into Aged Care Quality and Safety.

Scott Morrison holding final aged care report.
The final report includes 148 recommendations designed to improve aged care in Australia. (Image: AAP)

The new model, is contained within 148 recommendations included in the aged care royal commission’s final report, and is designed to encourage the provision of ‘holistic, coordinated and proactive’ healthcare – but the RACGP has some concerns.
 
In response to the report, the Federal Government has set aside more than $452 million to address ‘immediate’ shortcomings in Australia’s aged care system, with a major focus on strengthening aged care provider governance and improving oversight of home care.
 
According to the report, the planned primary care overhaul will attempt to solve access issues associated with the current fee-for-service model, which Commissioners Tony Pagone and Lynelle Briggs agree is partly due to the amount of funding available for GPs providing aged care.
 
‘We heard evidence about the problems with the fee-for-service funding model, particularly that it creates an incentive for care that responds to an episode of ill health, rather than encouraging care that proactively attempts to reduce the risk of ill health,’ the report states.
 
‘Primary health care practitioners are either not visiting people receiving aged care at their residences, or not visiting enough, or not spending enough time with them to provide the care required. Access to general practitioners will continue to be a challenge for people receiving aged care unless something significant is done to fix it.
 
‘Commissioner Briggs considers that … part of the problem is the way in which, and the amount that, general practitioners are funded. Commissioner Pagone agrees that the funding of general practitioners for people in aged care is insufficient and is an issue that requires consideration.’
 
As a result, the commissioners have agreed with recommendations previously tabled by the Counsel assisting – QC Peter Rozen and QC Peter Gray – to establish a voluntary primary care model for people receiving aged care that contains the following characteristics: 

  • general practices could apply to the Australian Government to become accredited aged care general practices
  • each accredited practice would enrol people receiving residential care or personal care at home who choose to be enrolled with that practice
  • each accredited practice would receive an annual capitation payment for every enrolled person, based on the person’s level of assessed need
  • the accredited practice would be required to meet the primary health care needs of each enrolled older person, including through cooperative arrangements with other general practices to provide after-hours care
  • participation would be voluntary for general practices and patients.
However, while both commissioners support the establishment of a new model by no later than 1 January 2024, they differ on its implementation.
 
‘Commissioner Pagone recommends that the Australian Government should trial such a model for 6–10 years, after which time the Australian Government should undertake a thorough evaluation of the model,’ the report states.
 
‘He considers that a trial is necessary to determine whether it is viable to adopt a different model to improve access to health care for people receiving aged care.
 
‘Commissioner Briggs considers that the new primary care model for older people using aged care should be adopted now as it is the only viable option to address older people’s health access problems and will provide for better management of chronic and complex health conditions. She recommends that the model should be reviewed for enhancements progressively.’
 
The RACGP has previously expressed concerns about such a model, stating that while accreditation could see general practices receive an annual capitation payment, it would be attached to a requirement to provide after-hours care, along with an obligation to accept any person who wishes to register with them (subject to geography).
 
It would also see practices held to account against a range of performance indicators – including immunisation and prescribing rates – require them to initiate and take part in regular medication management reviews, and compel practices to prepare an ‘Aged Care Plan’ for each enrolled person that includes referrals for appropriate allied health services and dentistry.
 
The submission states that these shortcomings could in fact serve as further barriers for GPs providing care to aged care residents.
 
Other recommendations that relate directly to general practice include:
  • the establishment of a ‘comprehensive, clear and accessible’ post-diagnosis support pathway for people living with dementia, their carers and families, by 1 January 2023
    • as part of this, the Australian Government should provide information and material to GPs and geriatricians about the pathway and encourage them to refer people to the pathway at the point of diagnosis
  • improved public awareness of aged care by funding and supporting education, and the dissemination of information, by 1 July 2022
    • part of this strategy involves bringing older people’s GPs to the centre of planning for ageing and aged care
  • by 31 December 2021, the RACGP should amend its Standards for general practices to allow for accreditation of general practices which practise exclusively in providing primary health care to people receiving aged care and in their own homes
  • the creation of specific Medicare Benefits Schedule (MBS) items to improve access to medical and allied health services
  • amend the Pharmaceutical Benefits Scheme (PBS) Schedule by 1 November so that only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care
    • GPs would only be able to issue repeat prescriptions of antipsychotics as a pharmaceutical benefit for up to a year after the date of the initial prescription.
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Dr Kathryn Joyce Lees   2/03/2021 6:52:16 AM

If I am visiting a person with behavioural issues at the weekend I will be very unlikely to be able to get a geriatrician or a Psychiatrist there on the day to issue the first antipsychotic script. Antipsychotics should be like narcotics, yearly review by specialists.

I think bentos will just replace the antipsychotics.


Dr Michael Lucas Bailey   2/03/2021 7:30:50 AM

All these proposed funding models fail GPs. The key issue is that most GPs work in general practices as individuals NOT for general practices. Capitation funding is more likely to disincentivise GPs as it increases the individual responsibility and medico-legal risk but reduces the individual incentive. Whether that is aged care or chronic disease.

Funding is only part of the problem in aged care anyway. Facilities themselves need to provide adequate care to patients before GPs can accept the medicolegal risk of having involvement with the facility.


Dr Graham James Lovell   2/03/2021 8:31:52 AM

I will be still initiating antipsychotics if needed come November 1st. It will just be a private script until the Geriatric service can review. Being a Geriatrician doesn’t make you better at judging medication management than a GP in this context, when they see them on a one off basis, but you know them on an ongoing basis, plus have an ongoing update from the regular nursing staff. There are already clear recommendations on regular reviewing and attempted weaning of these agents.


Dr Duncan MacWalter   2/03/2021 8:37:54 AM

Anyone who has worked in UK primary care will know capitation disincentives patient contact. That’s because income remains stagnant, but costs rise, leading to subcontracting to nurses, paramedics, or even healthcare support workers, all to break even.
This fragments care for an already vulnerable group.

If we’re talking radical but sustainable solutions, aged care work should be salaried, at rates akin to hospital specialists. Defined workloads and reasonable salary packages will actually draw in the best staff, through competition.

High quality care is difficult to delivery consistently on low budget.


Dr Ian Mark Light   2/03/2021 10:51:09 AM

It requires great skill and compassion to treat the altered behaviours that happen with cognitive impairment .
A GP needs to exclude infection pain dehydration medications amongst other causes and then have ability in behavioural management of agitation wandering aggression and apathy .
A GP needs to know if the aged care facility they are attending has abilities in place to manage infection control pain management medication review and psychological distress .
Often over worked understaffed and overwhelmed nursing staff request medication for patients to help with residents insomnia and outbursts of distress .
There is a lot of time and commitment needed in aged care and general practice has the capacity .


Dr Ralph Mangohig   2/03/2021 12:34:09 PM

'Often over worked understaffed and overwhelmed nursing staff request medication for patients to help with residents insomnia and outbursts of distress .'
I could not agree more. I commend any solutions to improve funding for GPs to provider better care, but there needs to be higher nursing to resident ratios who are trained in non-pharmacological management of dementia related behavioural problems. And the role of non-medical carers should not be understated also. They by far spend the most time with patients in their activities of daily living and provide a rich source of collateral history for the visiting GP providing assessment and management.


Dr John Michael Jones   2/03/2021 6:58:38 PM

I have been seeing patients at RACF for nearly 20 yrs. I initially would respond to calls from the NH but quickly realised that seeing the RACF patients on a weekly basis made a huge impact on their care and wellbeing. In the process of weekly visits I was able to strengthen the Dr Patient relationship and it meant I knew the patients as well as the regular nurses and a lot better than the locus nursing staff. IMO Working together with the RACF Staff and individual residents is the only way to maintain care - further bureaucratising the the process is a typical paternalistic government response that is doomed . GPs work as individuals and have a responsibility to their patients they actually need support to do this which to date has been lacking


Dr Pradeep Samarakoon   2/03/2021 11:23:21 PM

Although this could be hard to understand to a capitalist, care of the vulnerable persons (childcare, youth and care of the elderly) should not be entrusted to profit oriented businesses (including healthcare). Instead should be handled by not for profit organisations. Does a parent care for their child for the money? Does a son or a daughter care for their parent for money? Proper care of the vulnerable person cannot happen in a cost efficient production line. Well paid, well trained staff with defined sustainable workloads is a good start. No one deserves to be neglected when they are "no longer useful".- one day we all will. Suitable alternative to a caring parent or a son or a daughter will be hard to find!


Dr Pradeep Samarakoon   3/03/2021 6:59:21 PM

Although this could be hard to understand to a capitalist, care of the vulnerable persons (childcare, youth and care of the elderly) should not be entrusted to profit oriented businesses (including healthcare). Instead should be handled by not for profit organisations. Does a parent care for their child for the money? Does a son or a daughter care for their parent for money? Proper care of the vulnerable person cannot happen in a cost efficient production line. Well paid, well trained staff with defined sustainable workloads is a good start. No one deserves to be neglected when they are "no longer useful".- one day we all will. Suitable alternative to a caring parent or a son or a daughter will be hard to find!


Dr Roberto Celada   8/03/2021 3:12:10 PM

I enjoyed working for 4 age care facilities for about 30 years. I visited regularly once a week and after hours when needed. I was on call 24/7. I had to get out of bed to see a resident only once or twice a year. We had specific plan of action for each resident and most of the after hours issues were resolved over the phone. 90% of residents were able to die at the ACF with excellent palliative care. Income was good as I did CMAs, review care plans, medication reviews, after hours payments etc.
Each ACF provided me with a dedicated nurse for my session, fully equipped office, consumables, Best Practice software and anything I asked for.
Unfortunately I retired as I am now over 66.
With good systems in place and support from the facility, age care work is great!
Thanks
Roberto


Dr Robert Denis Roche   31/03/2021 9:43:40 PM

agree with alot of comments and frustrations above. Very unlikely to find geriatrician in middle night or within 2 weeks of requirement of antipsychotics for significant BPSD, As most of those Gp working in this particular sector have a lot of experience and try to not facilitate needless referrals to over worked or inadequate community geriatric services ( not due to their lack of support but more lack of manpower) they should provide some upskilling so so with experience and possible local upskilling can be allowed to have access to prescribe antipsychotics. Othwerwiser either client and family or out of cost , we send to DEM more often to manage what we can usually manage or this system ends in turmoil as some of us give up RACF in frustration. Also a lot of GP doing aged care do not do it through there practice ( as usually corporate owne) so giving extra PIPs equivants does not benefit the GP doing the work or encourage any one to take up the extra workload.