Coronavirus crisis exposes fundamental flaws in our healthcare system
Published in The Age, March 13 2020
When a system is under stress – as our health services are now – cracks and strains become apparent that may otherwise have been easy to overlook. Australia’s response to coronavirus is constrained by the fundamentals of our health system, which are hindering management of the pandemic.
Primary care in Australia, which should be the front line of any service response (in contrast to a quarantine or social-distancing response), is delivered via a 1950s-style, GP-centric, fee-for-service model. It is already widely regarded as not fit to respond to the changing epidemiology of the increased prevalence of chronic disease in Australia and our response to coronavirus shows it is not fit to respond to an infectious disease pandemic either.
The initial advice from health authorities in Australia was that people who had travelled to certain countries and exhibited flu-like symptoms should seek testing from their GP. This advice reflects the GP-centricity of primary care in Australia, including that there is no systematic approach to paying for testing by any other provider.
The media over the past few weeks has been dominated by representatives of general practitioners and the broader medical profession bemoaning the lack of personal protective equipment, poor distribution of masks, and the failure of public health authorities to provide regular updates on the pandemic.
Health authorities have finally moved to establish “fever clinics”, but they are often based in hospitals and we have ludicrous pictures of patients waiting in line for testing. Thankfully, the nation’s first drive-through clinic has now been established in South Australia and there have been a few good-news stories of innovative GPs establishing drive-through testing.
Australia’s advice and response is in stark contrast to the response in England. Over the years, England’s National Health Service, or NHS, has developed its telephone advice capacity. It has an easy-to-remember phone number – 111 – and a stronger pattern of nurse-led primary care.
Unlike the Australian advice – to visit a doctor – the NHS advice was to call the hotline and not to visit a doctor. The treatment advice to GPs for people who did visit the doctor was essentially to isolate them in a room and get them to call 111. Nurse-led, drive-through testing was established in London more than a week ago to reduce the chance of transmission through the health system.
The British response was possible only because of a systematic strategy over years to focus GP time on those patients who most require the diagnostic and treatment skills of a GP and to encourage the community to seek advice about when a visit to a GP was really necessary.
Minimising GP visits is not a good business proposition for private GPs in Australia because they get paid on a fee-for-service basis: the more patients through the door, the more revenue for the practice. But minimising GP visits makes a lot of sense in Britain, where the payment system for GPs is more sophisticated: they are paid an overall fee to manage a patient’s care plan.
Australia, unfortunately, has not started on such a reform journey and may not ever be able to do so given its history and starting point.
Another symptom of a system under stress was the calling-out of a Melbourne GP, Dr Chris Higgins, who contracted coronavirus but continued to work, putting at risk about 70 patients. Dr Higgins had cold or flu-like symptoms but (reasonably) thought it unlikely to be coronavirus. He continued to see patients in his Toorak rooms and visit his nursing home patients. The Victorian Health Minister was “flabbergasted” that he did so, a criticism that sparked outrage from the medical profession. Most tellingly, one of the defences of Dr Higgins’ actions was that GPs are stretched so thinly that they have to work when sick.
General practice is still essentially a cottage industry in Australia, with the average practice size about seven GPs, together with a few nurses and administrative staff. This highly GP-centric model means that it is hard to call in a replacement if a GP is sick. So the GP gives priority to seeing patients, rather than protecting those same patients from the risk of infection.
A system which requires such a trade-off should not continue. Australia needs quite a different practice organisation, possibly one that links practices into a larger network and changes the service model to rebalance the workforce and increase the role of practice nurses.
Eventually Australia will move out of the crisis phase of the coronavirus pandemic. When that time comes, we should reflect on whether our system of primary care helped or hindered our response and how we might better use modern technologies and the skills and talents of all health professionals.
It is clear that we need better ways to give health advice and care, not just in the next pandemic but as part of our routine delivery.