Voluntary patient enrolment with a single primary health provider: should we consider it?

 

The National Hospital and Health Reform Commission Report recommended the option of voluntary patient enrolment (Recommendation 18) with a single primary health care service for at-risk people and groups. Why is it a good idea?

 

The better the primary care, the better the health outcomes, and the greater the reduction in health disparities. This leads to greater cost savings. The core of that care is general practice, and the continuous therapeutic relationship between a patient, a doctor, and the team that supports them.

 

Some academics use the term ‘medical home’, which means a patient centred, multifaceted source of primary care for a particular patient. There is much evidence to support that this care both saves lives and is valued by the community.

 

A study of several patients with 11 different conditions demonstrated that patients had more monitoring of their conditions if they received care within a continuous care plan, as opposed to disease specific speciality care.

 

GPs are both gate keepers and gate openers. This system both improves care and reduces costs. GPs can multi-task across a number of specialities. Research shows that patients who consult the same doctor have higher assessments of all dimensions of primary care. This translates to greater respect for the general practitioner.

 

55 per cent of over 65s have five or more chronic conditions. An Australian Institute of Health and Welfare study showed GP management of type 2 diabetes has increase by 57% in the past ten years. The cost of providing care is set to escalate, with an ageing population and an increase in chronic disease in the general population. We need to be able to provide that care in better and more cost effective ways.

 

The Commonwealth Fund’s recent International Survey of Primary Care Physicians from 11 countries showed that the four countries with the highest ‘physician satisfaction with practicing medicine’ rates also have patient enrolment schemes in place.

 

There are three parts to continuity of care: Relationship continuity, information continuity and management continuity. The best results for patients come from systems that facilitate all three.

 

Continuity of care is critical for particular patient groups.  It matters in mental health, in the early detection of many conditions, in chronic disease management and it matters when prescribing drugs of dependence.

 

It is particularly difficult for urban practices to provide continuity of care. Medicare data shows that of those visiting a practice less than once a year, only 47.8% attend a single doctor or practice.

 

This statistic is likely to be worse if you separate metropolitan from rural or regional areas. With the decline in continuity we see less satisfaction for the doctor, less respect for general practice and more fragmentation of care. Fragmentation of care is a key concern, particularly when we talk about nurse practitioners working in isolation. It applies to us just as much when multiple GPs are involved in one patient’s care.

 

If a person with one or more chronic illnesses attends several practices, who takes responsibility for managing the patient’s problems? Who has the full patient history? Who knows what medications are being taken?  Who knows what investigations and referrals have been done?  Who do the hospital send letters to?  Who does the pharmacist ring when there is a problem with medication or clarification is needed? It is a dog’s breakfast.

 

Multiple prescribers multiply prescribing errors. Patients are more likely to double up and get confused with medication, or be prescribed medication that will interact badly with other medication. Multiple investigations with multiple players costs the tax-payer more. We are already facing escalating costs. For example, pathology costs have nearly doubled in the last 10 years.

 

GPs are managing more chronic conditions now than in the past ten years. It is time we were given the tools and the teams to do it even better. That means support for better infrastructure, support for improved practice teams, and funding which rewards quality, not quantity.

 

No government will increase funding to general practice without a better model. We need an AMA that will support these changes, not hinder them. We need an AMA that will help us work through these proposals – advocating for GP led primary care.

 

This is not about restricting access to care. It is about providing better care. Countries like New Zealand that have patient enrolment do not restrict the patient from changing practices. With greater clarity about who your patients are the scope to improve patient outcomes increases.