Grant boosts af­ter-hours vis­its

A push to im­prove af­ter-hours GP ser­vices is bring­ing re­sults, but crit­ics say many ar­eas are still out in the cold. Health ed­i­tor Adam Cress­well re­ports

The Weekend Australian - Travel - - Health -

NEXT month a new GP af­ter-hours clinic will open in Ryde Hospi­tal, in Syd­ney’s leafy north-west sub­urbs. Noth­ing spe­cial there — the fed­eral Gov­ern­ment an­nounced its two-year, $200,000 grant for the cen­tre back in March, and it is just one of at least nine such clin­ics at NSW pub­lic hos­pi­tals an­nounced since 2001 at a com­bined cost of $7.2 mil­lion.

Ex­cept this one is a bit spe­cial. It is slap, bang in the mid­dle of the Prime Min­is­ter’s own Ben­ne­long elec­torate and its open­ing will doubt­less pro­vide a pos­i­tive photo op­por­tu­nity for a gov­ern­ment lag­ging in the polls, and for a lo­cal mem­ber whose very seat is threat­ened by a high-profile La­bor can­di­date, for­mer ABC jour­nal­ist Max­ine McKew.

That’s not all the Gov­ern­ment is do­ing for sub­ur­ban Syd­ney: in a lit­tle-pub­li­cised move it re­cently agreed to pro­vide $600,000 over three years for a new mo­bile af­ter-hours GP ser­vice to cover nearly 500,000 peo­ple in the city’s west. The ser­vice will be op­er­ated, in con­junc­tion with the lo­cal di­vi­sions of gen­eral prac­tice, by the Bris­bane-based Fam­ily Care Med­i­cal Ser­vices, which also has the con­tract to run the new Ryde af­ter-hours ser­vice.

FCMS is the coun­try’s big­gest af­ter-hours med­i­cal deputis­ing ser­vice, which pro­vides a way for hard-pressed GPs to en­sure their pa­tients con­tinue to have ac­cess to emer­gency med­i­cal care while they go home for the night.

To in­fer that the grant for af­ter-hours ser­vices in west­ern Syd­ney is a vote-win­ning stunt ar­ranged with the elec­tion in mind would be un­fair, as the need is great — west­ern Syd­ney has been one of the coun­try’s worst blackspots for af­ter-hours care.

It is also just the latest in a long line of such grants. The $600,000 grant is com­ing out of the cof­fers of the Gov­ern­ment’s Round the Clock Medi­care ini­tia­tive, which since 2005 has al­lo­cated grants worth a to­tal of $62.5 mil­lion over five years to more than 140 such af­ter-hours ser­vices.

GP or­gan­i­sa­tions say plenty of gaps still re­main in af­ter-hours cover, par­tic­u­larly in rural ar­eas. The fed­eral Op­po­si­tion, too, is quick to point out that the Gov­ern­ment has been spend­ing less than it said it would on some as­pects of the af­ter-hours pro­gram.

Ques­tions in Se­nate Es­ti­mates ear­lier this year es­tab­lished that al­though Medi­care re­bates for af­ter-hours vis­its were in­creased in Jan­uary 2005, ac­tual spend­ing on th­ese re­bates ran at about half the fore­cast level in both 2004-05 and 2005-06.

La­bor health spokes­woman Ni­cola Roxon said La­bor’s $220 mil­lion plan to set up GP su­per-clin­ics would ‘‘ pro­vide in­fra­struc­ture fund­ing to es­tab­lish a greater range of con­ve­nient and qual­ity ser­vices in lo­cal com­mu­ni­ties — par­tic­u­larly in rural and re­gional ar­eas and where Medi­care has not been utilised to its fullest ex­tent be­cause of work­force short­ages. This will in­clude ar­eas where af­ter-hours ser­vices do not ex­ist, or are poor,’’ she said.

FCMS’s chief ex­ec­u­tive and part-owner Stu­art Tait con­tends there has been ‘‘ a quite re­mark­able pe­riod of in­vest­ment and pol­icy de­vel­op­ment’’ in af­ter-hours care in the past decade, turn­ing around the sit­u­a­tion in the late 1990s where GPs fled the sec­tor in droves.

The re­cently ap­pointed pres­i­dent of the Na­tional As­so­ci­a­tion of Med­i­cal Deputis­ing Ser­vices (NAMDS), Tait says while more in­vest­ment has played a role, so have other mea­sures, such as find­ing the right mod­els that again make af­ter-hours care at­trac­tive for GPs. Money is part of that, but so is pro­vid­ing ed­u­ca­tional sup­port, ad­min­is­tra­tive sup­port, and ad­dress­ing se­cu­rity.

FCMS it­self is cer­tainly ex­pand­ing quickly on the back of the Gov­ern­ment-led in­vest­ment, which has taken the form of in­creases in the Medi­care re­bates for in­di­vid­ual doc­tors who see pa­tients af­ter hours as well as block grants to help es­tab­lish new ser­vices. Based in Bris­bane for over 30 years, FCMS has grown four-fold in five years and now cov­ers the whole of the greater Bris­bane area from Noosa on the Sun­shine Coast in the North to the Gold Coast in the south, and west to Ipswich. It han­dles 200,000 pa­tient con­tacts a year in Queens­land, and 100,000 con­sul­ta­tions — 75,000 as home vis­its and 25,000 at the surgery.

FCMS also runs af­ter-hours clin­ics colo­cated with hos­pi­tals at Ca­bool­ture, Caloun­dra and Logan, and re­cently opened a stand­alone clinic at Kal­lan­gur. The com­pany re­cently ex­panded into Syd­ney, buy­ing the af­ter-hours ser­vice cov­er­ing the city’s north­ern sub­urbs.

GPs pay to sub­scribe to the ser­vice, pay­ing about $230 per month for each full-timee­quiv­a­lent GP in the prac­tice. For this, the GPs can have calls to their prac­tice au­to­mat­i­cally di­verted af­ter-hours to the FCMS call cen­tre, where med­i­cal re­fer­ral as­sis­tants — some of whom are nurses or med­i­cal stu­dents — take the de­tails and clas­sify the pa­tient into one of seven cat­e­gories for a doc­tor to as­sess.

If the doc­tor can tell the prob­lem is triv­ial, he or she might be able to ad­vise the pa­tient how to treat it them­selves, or visit their GP the next morn­ing. In more ur­gent or less clear-cut

From Health cover cases, a locum doc­tor may be sent out to visit the pa­tient in their own home.

If this hap­pens, the pa­tient is billed in much the same way as if they were see­ing a day­time GP. Pa­tients are bulk-billed if they are pen­sion­ers, con­ces­sion card hold­ers or chil­dren un­der 16 — a cat­e­gory that cov­ers 90 per cent of the call-outs. In other cases, the typ­i­cal gap — the fee over and above the value of the re­bate the pa­tient gets back from Medi­care — is about $20 to $25, or ‘‘ about the cost of a pizza’’, as Tait puts it.

Doc­tors who work for FCMS — in many cases GPs who trained over­seas and are re­stricted to work­ing in ar­eas of med­i­cal work­force short­age, a cat­e­gory that in­cludes af­ter-hours care, for a 10-year pe­riod — are con­trac­tors who re­tain the Medi­care earn­ings they gen­er­ate, af­ter FCMS sub­tracts a set-per­cent­age man­age­ment fee.

This is in ex­change for the con­sid­er­able ad­min­is­tra­tive and lo­gis­ti­cal sup­port that FCMS pro­vides. Not only does the ser­vice look af­ter the Medi­care pa­per­work, it main­tains a fleet of cars, and pro­vides its GPs with dress­ings and med­i­ca­tions so pa­tients can be started on an­tibi­otics or other drugs straight away, rather than wait­ing un­til they can ob­tain a script the fol­low­ing day. GPs are is­sued with Black­berry com­mu­ni­ca­tions de­vices to en­sure they keep in touch on the road, and the pa­tient’s own GP is faxed a sum­mary of the visit the next work­ing day.

Tait says ad­dress­ing the se­cu­rity is­sues has helped at­tract fe­male GPs back into afterhours care, af­ter many were put off fol­low­ing a cou­ple of in­ci­dents in the 1990s in which af­ter-hours GPs were at­tacked, or even mur­dered. FCMS sends its GPs out with chap­er­ones, who es­cort the doc­tors to the door of the res­i­dence and can pro­vide sup­port if trou­ble looms; it also equips them with duress alarms so the GP can alert the chap­er­one that this is hap­pen­ing.

GPs are not despatched in the first place to see pa­tients con­sid­ered po­ten­tially dan­ger­ous, as recog­ni­tion soft­ware in the call cen­tre de­tects phone num­bers and ad­dresses that have been pre­vi­ously flagged as prob­lem­atic. Drug-seek­ers would get lit­tle joy: to re­duce the in­cen­tive for trou­ble, FCMS doc­tors do not carry the opi­ate or other drugs that ad­dicts crave.

De­spite the size of its cov­er­age ar­eas, FCMS says 80 per cent of its call-outs are done within three hours, and 50 per cent within 11/ hours — far shorter than the

2 wait­ing pe­ri­ods many of th­ese pa­tients would face if they chose to at­tend their lo­cal hospi­tal emer­gency de­part­ments in­stead.

As fig­ures con­tinue to show fewer and fewer in­di­vid­ual GPs do­ing their own afterhours home vis­its for their pa­tients, is this the fu­ture of af­ter-hours care?

Daniel Chew, one of FCMS’s GPs, says the work is pro­fes­sion­ally re­ward­ing al­though it can also present chal­leng­ing sit­u­a­tions, such as a se­verely de­hy­drated child or a child with un­con­trolled fever who was also have trou­ble breath­ing.

‘‘ I find that when I come to see pa­tients at home, they are more com­fort­able than if they were wait­ing in an emer­gency de­part­ment,’’ he says.

How­ever, it’s not all rosy. Tait ad­mits that while all the cap­i­tal cities are rea­son­ably well catered for, ex­cept his­tor­i­cally Syd­ney which has had lit­tle cul­ture of af­ter-hours vis­its, in rural ar­eas it’s a dif­fer­ent story.

Tony Hobbs, chair­man of the Aus­tralian Gen­eral Prac­tice Net­work, rep­re­sent­ing 119 ge­o­graph­i­cally-based ‘‘ di­vi­sions’’ of gen­eral prac­tice, agrees the rural sit­u­a­tion re­mains a prob­lem and how best to solve it of­ten has to be sorted out ac­cord­ing to what suits lo­cal con­di­tions.

‘‘ We have six GPs in this town (of Coota­mundra) and we have a co-oper­a­tive af­ter-hours ar­range­ment where we each take it in turns,’’ Hobbs says. ‘‘ Some­times you are on call one day a week, some­times two.’’

In ar­eas where GPs are scarce, par­tic­u­larly the more re­mote ar­eas cat­e­gorised as in RRMAs 4 to 7 (a ref­er­ence to the fed­eral Gov­ern­ment’s rural clas­si­fi­ca­tion sys­tem, on which many grant and in­cen­tive ta­bles are based), deputis­ing ser­vices such as FCMS are sim­ply not an op­tion be­cause there is nei­ther the pa­tient nor GP pop­u­la­tion to sup­port them.

Hobbs says di­vi­sions are well placed to work out lo­cal so­lu­tions to af­ter-hours ros­ters — an im­por­tant step since oner­ous on-call du­ties put off many doc­tors from mov­ing to rural ar­eas, ex­ac­er­bat­ing the rural doc­tor short­age.

‘‘ If you are in your 50s or early 60s and if you have an oner­ous on-call re­spon­si­bil­ity, (re­tire­ment) is an easy de­ci­sion to make,’’ Hobbs says. ‘‘ If that bur­den is re­moved or re­duced, you would be more likely to stay in the work­force.’’

Pic­ture: Tony Phillips

Night call: Fam­ily Care Med­i­cal Ser­vices doc­tor Daniel Chew on an af­ter-hours call with chap­er­one David Rose (left)

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