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    Vicki McCartney

    AFTER HOURS – an essential part of good health care but are we be creating a 24/7 expectation of services? A “Supermarket mentality of convenience.”

    I have been watching the debate about after-hours care. There are many valid concerns & viewpoints. However, GPs should not be duped into thinking that we need to solve the disconnected Federal/State health system by working longer hours.
    It would be easy to make the Medical Deputising Services (MDS) the “bad guys” & the hard-working low paid GPs the “heroes”.
    Of course, this is not the case.
    Many original after-hours services were in fact cooperatives, based on an organised group of GPs banding together to provide services for their own patients.
    In recent times things have changed. MDS have evolved based on a profit focused, market approach to medicine – create a demand & provide the service the public believes they need. Health is emotive & many patients are vulnerable to feeling it is best to get advice & professional care now…” just in case”
    I was involved in a recent discussion about patients as “consumers”. Consumerism appears to empower them to not just be informed but to demand more services & products that may improve their health. Why not a service that gives you peace of mind when you are worrying about a symptom at 10 o’clock at night, especially when it appears to be provided for free.

    A significant number of conditions that require urgent care are best managed in an ED setting, as it provides the ability to investigate, treat & most importantly, monitor over time. This model of care is difficult for General Practice in the present model both structurally & financially. It is impossible for a MDS doing a home visit to achieve this level of care. Many concerns that patients have after-hours could best be triaged over the phone & many could afford to wait till the following day for review in “normal hours”. Phone triage is often done by GPs in rural areas, but it requires the GP to be available without any financial reward for this expert advice.

    Medicare is a great system of universal health care & one, that I would think, every Australian support. Any system using taxpayer’s money should have checks & balances. It seems strange, therefore that a Medical graduate who has completed their registration requirements in a hospital, can apply for a provider number to work for an “Approved Medical Deputising Service Program” & hence access Medicare payments. Their rebate may be lower (non-VR) but that just means they will need to see a lot more patients. The system essentially opens the door for MDS to provide a service that the “consumer” demands. There is no need for informed financial consent & in fact there is a lack of transparency when it comes to the price of the service.

    The reviews of ED presentations have not shown the expected outcomes. There are massive rises in afterhours Medicare claims without reductions in ED presentations. However, the dislocation of care & lack of communication is a concern perhaps less well understood by the patient.

    Is there a political will to actually control waste in health care?
    Should the Government:
    • control costs by limiting bulk billing to those truly in need rather than leaving it “up to the GP or MDS” to make these decisions.
    • be honest about the rebate being the patient’s universal health care benefit not the doctor’s payment
    • control provider numbers, (the real “hot potato”), especially as we start to produce excessive numbers of doctors?

    I don’t claim to have all the answers but I am concerned that suddenly changing the business model for MDS so they become unsustainable, is not the best solution.
    • I am concerned that asking GPs to work more or be available to refer patients in the after-hours period does not fit with a safe working hours approach.
    • I do believe there needs to be the ability for doctors to be appropriately trained if they are going to work in a MDS. If we are trying to reduce costs & presentations to EDs then it is possible MDS have a place in the system, and may be a model of afterhours care in which we need to invest. All parts of the Health care system need to be linked so the patient can have: “the right care, in the right place, at the right time.”
    • If MDS were required to have a true working relationships with General Practice & their rebates were tied to this requirement, we may provide what the consumer demands – place based care. Rather than take a punitive approach it makes more sense to reward high quality services that are able to develop these relationships & extend the capability of General Practice.
    • Could an in-hours GP follow-up appointment (specific item number) be required for the patient to be able to claim their “after hours rebate”?
    • Do patients have a right to “non-urgent services” such as a work certificates or scripts in the after-hours period? Perhaps the answer is “yes” if they are prepared to pay for it & know Medicare does not cover this. That is truly the consumers’ ability to make informed choices. If the MDS & GP are linked, then the information would be shared with the usual GP.
    • Lastly, if we believe that anyone claiming Medicare rebates needs to be appropriately trained, or in training, is it time to have a tighter control on provider numbers? There will always be debates about this but the taxpayer’s health dollars should be used judiciously.

    In summary, it appears that politicians from all persuasions want to promise an unsustainable amount of health care to prove they support Medicare. After-hours appears to have become a yardstick for this commitment. Is it time for an honest debate?
    The requirements of improved training for the doctors providing the service is a relatively easy “fix” especially as an oversupply of doctors is looming.
    The more important debate is whether greater accessibility of healthcare at any hour is a realistic & cost-effective goal. Do we want to promote a “supermarket mentality of convenience” as the goal for our health system?

    Dr Vicki McCartney
    Principal GP at Moss Street Medical Practice
    Nowra NSW.
    Rural GP for 31 years.

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