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