Category Archives: International

General practice in Scotland and Australia: the experience of two GPs

Jane Gall and Derek Wooff, are both general practitioners who worked in Stranraer, Scotland for 26 years and have been working in Shepparton Medical Centre for the last 6 years.

General practice is a good job. It uses knowledge, experience, judgement and intuition to provide appropriate care and this complex process is both stimulating and rewarding. Currently with rising patient expectations and decreasing investment, solutions to workload issues may benefit from broader thinking and looking to other models of care.

We wish to reflect on our experience of translating care from the NHS in Scotland to Medicare in Australia.

We became emotionally exhausted attempting to continue providing the level of care expected by the population. 

Our background was working as general practitioners (GPs) for 26 years within the NHS model of care based in Stranraer, a small town in Scotland. We knew our patients and their families extremely well. We were truly part of a team with practice nurses, linking with district nursing staff and being part of the community hospital. This involvement provided professional satisfaction and support from a multidisciplinary team. There were many changes over the years and the team structure of General Practice allowed moulding and restructuring to changing demands. However, we became emotionally exhausted attempting to continue providing the level of care expected by the population with decreasing resources and increasing clinical governance. It was hard to manage workload and demand as well as fulfil the QOF (Quality and Outcome Framework) criteria and paperwork. It seemed the fun of the job had decreased with the doctor agenda rather than the patient agenda driving the consultations. We were concerned about moving out of our comfort familiar zone and working elsewhere without the ‘safety’ of background knowledge of patients and relationships that had developed from years of continuity of care.

Could we re-establish our professional satisfaction and feel the fun again of general practice by moving continent?

In 2010 we moved to Australia and took the opportunity of developing a medical student teaching GP clinic, which was a new development for the University of Melbourne. This challenge was growing a general practice business in Shepparton, a regional town in Victoria, Australia, within the Medicare system. When this opportunity arose for a ‘sea change’, we decided to take the plunge. Interestingly we found change and new beginnings are normal in the Aussie culture.

Adapting to a new model of care has been refreshing and interesting. Firstly, we realised that the therapeutic relationships with patients we value so much and had felt were partly built on years of continuity of care can be established quickly within a consult. This may be aided by years of experience although I do believe that active listening skills are the key. Trust can be felt at the consultation and so it can be a surprise when despite this patients do move around for care. The GP model of care in Australia allows patients to go to any GP practice at any time, so ongoing relationship care is viewed differently by both the patient and the professional.

We have considered the impact of this fundamental difference between the NHS and Australia primary care. The Australian system does encourage patients to take more ownership of their own care although it may result in over servicing and unnecessary repeat investigations. However, the GP is freed from the trapped feeling of patients being dependent on him or her as an individual. Patient autonomy and ability to seek second opinions is almost encouraged and facilitated in Australia. This can be releasing and helpful, although potentially confusing and may result in patients searching for the response desired by the patient. As there is little effective transfer of information or central data base to connect patient information, decisions can be made within silos of thinking.

Perhaps care could be considered in different contexts; acute and chronic. Acute consults sometimes including incidental task oriented requests like forms or repeat prescriptions and ‘chronic’ for more complex ongoing illness review. It appears that some patients seem to value continuity of care for chronic disease, while attending different ‘convenient’ practices for incidental or acute care. In some regard this does make sense as good background knowledge of medication tried and pathology results may be more important for management of chronic conditions.

The flexibility of provider of care allowed to each patient does alter the fundamental role of GP as the hub of the wheel and ‘gatekeeper’ that is strong in the UK model of general practice. The GP is part of the care, but not the truly essential coordinator in Australia. As stated, the care may then be inappropriate or with duplication at times but it can also provide appropriate convenient care, for example, antibiotics for a UTI in a timely and accessible manner at a consult near the where the patient may be shopping. However, there is no real way of stewardship of the public purse which will be providing Medicare back up payments for many visits.

In the NHS… some shift to patients accepting some accountability for their own care would be good to see.

Currently there are ‘care plans’ and ‘team care arrangements’ under the Australian Medicare scheme. These are used for ongoing complex illness and team care is for co-ordinating allied health referrals. This model applies well to some cases – for example patients with diabetes. It does encourage goal setting for individual patients with their ‘regular’ GP and review can be three monthly. The emphasis is focused on the individual patient in contrast to the QOF points in the NHS model which is doctor agenda and population care driven. Also there is current discussion regarding the ‘my medical home’ model in Australia to further incentivise care by one GP. This may help address some of the duplication and rationalise ongoing responsibility. I believe this may be of benefit particularly to the most vulnerable such as mentally unwell patients who may slip through the net. The responsibility by the GP in the NHS can be over-burdensome and some shift to patients accepting some accountability for their own care would be good to see, particularly given the current recruitment crisis of GPs in the UK. This requires understanding from society and a change from people feeling that totally comprehensive care is a right to encouraging capable individuals to play a more active part in their healthcare. GPs may then feel less trapped in impossible positions within the NHS model of care.

A huge learning area for us has been understanding the business financial differences within general practice in the two countries. The curious bit is considering how this affects care delivery both from a patient ‘consumer’ perspective and from the professional point of view. Our practice in Australia followed a ‘bulk billing’ model until recently. This model survived on Medicare rebate income from item of service and was effectively free to patients. Translating across from the NHS, this model fitted our beliefs of having no barriers to accessing primary care. However, we have now a deeper understanding of Australian Medicare and appreciate this government support is essentially present for those who have healthcare cards and so fit the criteria for free care. Interestingly, others often wish to pay their way as part of their expectation and own feeling of self-worth, not misusing the ‘free’ system. This seemed to us an interesting cultural shift from the British feeling of their rights as they have paid taxes to the Australian view where they feel it is appropriate to contribute and often have a higher regard of value when linked to a higher cost. However, there are some patients on the borderline for ‘healthcare cards’ which is the entitlement to free care and so are charged for consults thus may find cost a barrier to seeking appropriate primary health care. Using judgement to allow bulk billing could allow discretion to the most vulnerable but still lacks the guarantee of access to primary care for all. We do believe access to primary care is a fundamental right and it is a professional duty to manage this demand supported by broad discussion with society.

Our view is that there is value in adopting the best of both models of care.

The concept of ‘my medical home’ with continuity of care for patients with chronic illness while still allowing patients to access convenient care for acute problems may be a hybrid that could be considered. Ideally some linkage of electronic health records would support some mobility of patients and safety net patient care, while helping to reduce duplication and unnecessary investigations. This is truly a challenge for health care everywhere.

Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland.

Within the consultation, a focus on patient driven agenda with individual patient health goals is important. This may result in more engagement and accountability by individual patients and some of the dependency which exhausts individual general practitioners would be alleviated. One challenge is how to maintain clinical governance and standards of care within such a wide scope of work. Measuring outcomes can miss valuing the skills of navigating multiple co morbidities and providing appropriate holistic care. Knowledge and skills that are hard to define or measure are key to implementing appropriate individual care.

The engagement with individual patients resulting in improved professional satisfaction is still possible and the fun can certainly bubble up again. Recognition of the importance of primary care and managing public expectations are key to helping the bubbles rise up again. Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland. However, general practice in Scotland would benefit from review to alleviate the exhaustion of unrealistic patient demands and impossible society expectations. General practice is a complex job so any adjustments are complex but without recognition of the value of the job along with adaptation and changes to the job, there is a risk of loss of the essence, fun, effectiveness and professional satisfaction for the next generation.

General practice is still a wonderful job.

BJGP Blog Christmas charity: Help Malawi medics this Christmas

christmas_pound-1Perhaps you are thinking of giving of some money to charity rather than sending Christmas cards or maybe you want to give a different type of gift package. Or maybe you’d  just like to support a worthy cause. UK registered charity Medic to Medic supports disadvantaged students training at the College of Medicine in Malawi by providing student scholarships. Here’s an update on the work they do and the problems faced by medical students in Malawi.

“On the opening day of school, a few students litter the registry whilst a multitude are packed at the assistant registrar’s office pleading for waivers in order to get registered. Many have come as far as Karonga, the district bordering Tanzania and Zambia on the far north. The queue is slowly winding the pillars, meandering back and forth outside the assistant registrar’s office. At the dean of students’ office, there is an uncomfortable sight of premedical students wrestling the queue, pushing and dragging one another to the back on a hot summer day longing to meet the dean of students. Both students standing at the Assistant Registrar’s office and the Dean’s office have one problem akin to them; the insufficient tuition fee.

Following the overwhelming tuition fee hike of 600% at the College of Medicine, the students at the only medical school in Malawi are in dire situation and are languishing due to the inhumane hike. About 60% of the students have failed to register for the 2016/17 academic year and others have opted to withdraw temporarily on financial grounds.

The fee hike has rendered many students destitute as it comes at a time when Malawi’s economy has nosedived into oblivion. On the household level, most of the people in Malawi about 80% are in the rural areas and many of the students are from the rural areas where poverty has sky rocketed. In the villages, the parents can hardly afford three meals a day and most of them are going to bed on empty stomachs. If the parents can’t afford a descent daily meal, where will they get the huge money demanded of them to educate their children with the fees at 350,000 Malawi Kwacha (£400) per annum?  The only resort for the impoverished students is to ask for temporary withdrawal since they cannot get admitted in the college.

Malawi ranked the world’s poorest nation has been marred with intermittent blackouts, inconsistent water supply and insufficient harvest as the result of climate change. It is unbearable for medical students to be attending lectures as well as clinical sessions at the hospital on an empty stomach. Following the non-residential policy put in place about half a decade ago, more than half of the students at the college live outside the campus where their security is very unreliable, poor studying environment, pitiable sanitation and very high rentals.

Currently, the future of Malawi’s competent health practitioners hangs in the balance as mass withdrawal of the students on financial grounds has already commenced and it ought to deteriorate in the second semester if the current situation persists. The battle to reduce the fees had taken the students to the state president of the republic of Malawi who also doubles as the university of Malawi chancellor but it yielded almost nothing as the fees were only slashed by about fifty-five pounds from about four hundred and fifty pounds. The present situation for the medical students at College of Medicine is worrying.”  Fatsani Gundah, MBBS year 5 student.

UK registered charity Medic to Medic supports disadvantaged students training at the College of Medicine in Malawi by providing student scholarships. Scholarships cover the cost of tuition fees, provide a twice yearly stationery allowance, medical books, medical equipment and if funds allow, a laptop. This enables each student to study optimally so that they can fully concentrate on their studies and successfully qualify as health workers in Malawi, a country that has just 2 doctors for every 100,000 people.

Malawi desperately needs more health workers. It has some of the worst infant and maternal mortality ratios in the world. For many of the students training at the College of Medicine, the tuition fee increases are unattainable and there are more students struggling than ever before. Many students will be forced to drop out of their training, go back to their villages where the cycle of poverty will continue. Normally Medic to Medic have been able to take on 15 new students each year, but because of the 600% tuition fee increase, they have not been able to take on any new students.

This Christmas you can support Medic to Medic by buying a gift package for a loved one from their website. There are pre-set amounts starting from £10, through to £1,000. Each package goes towards a different aspect of a students training, ranging from paying for a stationery allowance, through to providing a laptop, medical pack and covering tuition fees. For each gift the recipient will receive a certificate, student profile, their latest student update and a selection of Medic to Medic gifts. Gifts can be sent direct to the recipient or back to the buyer. Packages can be sent internationally, although there is a minimum donation for these packages. It’s also possible for overseas friends to purchase gifts online in their own currency.

In an era when not knowing what to get someone for Christmas is such a first world problem, Medic to Medic offers a solution: an ethical gift of giving this Christmas.

For more information please visit:
www.medictomedic.org.uk
Email: info@medictomedic.org.uk
Call 0208 869 3603

Tales of the Saudi causeway

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

IMG_3931The island Kingdom of Bahrain, sits like a hotter, sandier version of the Isle of Wight in the sparkling blue waters of the Arabian Gulf. It is joined to the Saudi mainland by a 25 kilometer causeway. There is a certain soap opera fascination about driving in Bahrain. Cars weave in and out on the multi-lane highways, undertaking, overtaking, wombling free. I admire their skill. Leave a foot more than a car’s length in front of you and another car will cut in. And before stopping at a red light check in your mirror whether or not the guy behind looks like he might stop too. One drives defensively and gets used to it.

Driving in the Middle East is one of the last legal blood sports. You are three times more likely to die in an RTA in Bahrain than in the UK. But this brings us back to Saudi, where you are ten times more likely to die than the UK. (Top tip – when your taxi driver in Riyadh smilingly tells you not to worry that the seat belt isn’t working, find another taxi.)

The Saudi causeway is best seen from above, after one takes off from Bahrain International Airport. Its elegant curves show exactly what oil wealth plus a few good engineers can achieve. In fact, it is much better seen from above; the first rule of driving in Bahrain being don’t go across the Saudi causeway. It carries over 20 million people a year, but most traffic is at the morning and evening rush hours. Try it at 8pm and you might do it in 30 minutes. Try it at 8am and expect to take 3 hours. (The record in 2014 was an eight-hour traffic jam.)

IMG_7997A colleague, a local Ophthalmologist, told me of the shrewdest use of the causeway. He removed a cataract from a wealthy Saudi in a private Bahraini hospital. The Saudi was so delighted that he insisted on giving my colleague a camel – a high status gift. Sure enough the Saudi drove across the causeway, with the camel in a large horsebox. But camels are not allowed across the causeway, so he was stopped at the customs island, half way across. So my colleague was phoned and had to drive across the proximal half of the causeway to greet his patient (and of course the camel), with much hand shaking and back slapping all round, for it would have been a grievous insult not to have gone. With expressions of great regret they both agreed that every effort had been made, and the camel returned to the endless Saudi sands. So if you want kudos for a valuable gift without the expense, remember where you heard it first.

The point of this tale is that it is absolutely true. With such cultural disparity why should we be surprised by different attitudes to safety? Why should I be surprised to see families driving at speed with young children’s heads through the sunroof, or toddlers sitting on the driver’s lap? Cars have mounted the pavement at speed on three occasions approaching the roundabout outside our apartment. Well, whoever would think that you might have to stop? Although of course roundabouts make excellent parking spots (but only double park on a roundabout on a Friday). I have seen a driver reverse around this busy roundabout whilst talking on his mobile phone. The rate of road traffic accidents in the Middle East isn’t going to reduce any time soon.

So, back to the causeway. It is a dual carriageway, accessed by half a dozen toll booths with passport controls on both sides. So six lanes at the toll booth go into each two lane carriageway. There is no British queueing or alternate merging, it is just a free for all. And at rush hour it becomes anarchic. A friend, let’s call him Tom, told me of his first time across. He was in an unpropitious lane and had to push in to another to actually move forward. The cars were bumper to bumper and no one would let him in. In his mirror he saw the queue behind him building up as his inability to push in timed out his remaining credibility. Eventually an Arab in the car behind got out and approached. He wound his window down, expecting an angry tirade. The Arab reached out and put his hand sympathetically onto Tom’s shoulder. “Be strong my friend, be strong” he said, and got back into his car.

The blue pyjama brigade: primary care in Lesotho

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

IMG_2833Here at RCSI Bahrain our students wear blue scrubs to hospital attachments, but it’s a long time since I have been in scrubs. With some trepidation I had agreed to take four final year RCSI students to work for a fortnight in a small hospital in Lesotho.

Lesotho is a small mountainous nation, landlocked within South Africa. 40% of the population live on less than 1 US$ per day and almost a quarter of the adult population is HIV positive. You are 10 times more likely to die in an RTA than in the UK, and 50 times more likely to be murdered.

I had never been to Africa before. We landed at Johannesburg airport to meet up with a larger contingent from Action Ireland Trust (AIT), an Irish charity involved with development work in Africa. I drove our students across South Africa as part of the bigger party in in a convoy of mini vans. This is the one task I do feel prepared for – after the Middle East even driving in Africa feels OK. The hotel is interesting; nothing seems to work except my air conditioning, which sounds like a small lawnmower.

Together with an AIT doctor I am to supervise our students doing appropriate clinical work. RCSI goes out every year. The Lesotho Medical Council already has our details and copies of our documentation. The actual registration process normally happens on the first morning, when we attend in person with our passports and some cash. But this time the computer says no. Since the last visit the registration process has been “improved” with help from a grant from the EU. It took interventions from an Archbishop, an Ambassador and a government Minister to get us registered. My registration certificate from the Medical Council of Lesotho is now a treasured possession.

And so I became part of the blue pyjama brigade. Myself, my AIT medical colleague and our four students, resplendent in blue scrubs, descended on a small hospital some 30km from Lesotho’s capital, Maseru. The hospital serves a rural population of 200,000. Five GPs with nurse support provide 99% of the medical care for this population via the hospital and a handful of remote clinics. They run the hospital together with a fabulous Hospital Manager and a Nursing Officer.

In Bahrain 30% of the adult population has diabetes and these generate the chronic medical workload. In Lesotho it is HIV and its progeny, TB and PCP. We see new cases every day in packed open access clinics. We see Pott’s disease, TB lymphadenopathy, miliary TB, the list goes on. Having worked in South London I’ve seen many stabbings but now I see my first ever spear wounds (and more ordinary stabbings for good measure). Almost everyone is anaemic. We admit sick kids and serious adult pathology. We deal with broken bones and lacerations. The GPs look after the inpatients also – there is no one else. Only major surgical cases can be transported to Maseru. A close member of a hospital staff member’s family is murdered but she still turns up for work.

IMG_2485We drive to an outlying clinic. I thought the potholes on the main roads were bad, but now we are driving over unmade roads in the hills, eroded and rough. Driving across a ploughed field would be easier. Yet driving each day across the hills and plains of Lesotho is heart wrenchingly beautiful. Changing the inevitable flat tyre was not so beautiful. We were quickly surrounded by smiling faces and helping hands but the smiles disappeared when an unreasonable payment was demanded. I remembered the stabbings we had seen. We gave out some Rand and left quickly.

To say this was a humbling experience is a cliché, yet so true. General practice in the UK is well developed, stressful and increasingly dysfunctional. In Bahrain it is developing rapidly, it is stressful but functioning unencumbered by politicians and micromanagement. In Lesotho it is an immediate battle of life and death. Our five Lesotho colleagues are facing an unthinkable tide of pathology and trauma. Despite Alma Ata and the Millennium Development goals the inverse care law lives on.

Volunteering in the Calais ‘jungle’

calais and france 003

Niamh and Emily en route to Calais

Niamh Scally graduated from Norwich Medical School in 2013 and completed foundation training in Manchester. She is currently enjoying an F3 year before starting her paediatric training in London later this year. She has an interest in health inequalities and care of hard to reach groups.

Emily Player is a GP trainee on the Norwich VTS scheme. She graduated from Norwich Medical school in 2013 and has completed an academic foundation programme in Norwich. She has an interest in medical education and nutrition as well as migrant health and healthcare for vulnerable groups.

We are both junior doctors, feeling helpless and frustrated by the current refugee crisis we decided to travel to Calais to help in whatever way possible with this crisis on our doorstep. We used our annual leave and boarded the Eurostar for the one hour journey across the channel.

We arranged volunteering through the ‘Refugee First Aid and Support’ group on Facebook. We booked our accommodation in the local youth hostel where we met fellow volunteers, arranged lifts to camp and recruited more volunteers including student mental health nurses and dieticians to our medical team.

As undergraduates we had both volunteered in an orphanage in Kenya and later, on elective placements worked in developing countries providing healthcare at a basic level. Now we volunteer in France, there were no ‘grown ups’, and a distinct lack of authoritative presence, with the exception of the police vans which guard and intermittently blast tear gas across the camp.

The days go rapidly, like in the NHS there is not much time to drink or wee and for this we are grateful as we have seen the toilets. We mostly saw URTIs, wounds, scabies and were often confronted with the symptom ‘all over body pain’. We are still unsure if this is due to the cold and damp conditions people sleep in, the malnutrition, the fatigue from ‘trying’ all night or if it is somatisation of the mental pain they suffer everyday when contemplating their situation – this bottleneck they have arrived at here in Calais, twenty miles across the channel from their goal of a better life in the UK. ‘Trying’ itself is an incredibly dangerous activity; one refugee died ‘trying’ in the 5 days we were in Calais.

14259_0_supp_3_795wqtWe were seeing around 200 patients a day when all three caravans were up and running, which solely depends on volunteers. We referred a handful of patients a day to the Le Passe clinic; a service ran by the government hospital in Calais. MSF had been running a similar service until the beginning of March, when their contract expired and their main efforts were relocated to Dunkirk. Examples of cases we referred to Le Passe included febrile children, a non-weight bearing unaccompanied 16 year old child who incurred a police brutality injury, a head injury inflicted by a local fascist group that requiring suturing and a 65 year old Syrian man alone on the camp complaining of palpitations, clinically in AF with oxygen saturations of 88%.

As healthcare professionals along with the refugee’s working as translators we treat numerous tear gas injuries, the dietician was able to give advice on refeeding syndrome to refugees on a hunger strike and together we refer on average 10 unaccompanied children to the youth team a day. The youth team, also volunteers, ensures the children have food, shelter and phone credit, they offer emotional support and a safe place to be during the daytime. They also provide information on staying in France and seeking asylum or expediting their application to the UK as vulnerable minors.

We couldn’t comprehend that there are children alone in the camp; other volunteers reassure us that there are often elders and friends looking out for them, but this doesn’t reassure us, this situation is not normal for anyone let alone a child. It is not normal to run away from tear gas. They are incredibly vulnerable to exploitation. More must be done by the EU governments to ensure these children are being protected. As one of the translators eloquently put, “we are living in the jungle but we are not animals”.

‘An eye for an eye makes the whole world blind’ – reflections on working with Syrian refugees

image Nikesh Parekh

Dr Nikesh Parekh

Nikesh Parekh is a GP trainee, a research fellow in ageing and part-time public health medical associate in London. Colin Tourle is a semi-retired GP in Hailsham.

There are 1.5 million Syrian refugees in Lebanon, of which the vast majority are hidden away in camps near the Syrian border. These are some of the most impoverished victims of the war in Syria, who lack the financial resource to travel further afield for safety.

With the support of Iasis medical charity (www.iasis.org.uk), we were privileged to travel to three refugee camps within a mile of the Syrian border in Lebanon’s Bekaa Valley to provide medical clinics.

The camps encompass vast swathes of land with back to back tents. Word would spread that doctors have come to offer free help and before long a mass of people, usually 75% women and children, would be gathered outside eager to be seen. Crowd control was nothing short of the chaos at a sporting event! It was hard seeing children queuing outside a dust filled tent waiting for us to see them when one could only feel they should be playing in a garden somewhere with a football or trampoline.

We had never quite anticipated how varied the presentations might be, from the expected urine and skin infections, to eczema, to renal stones, to muscle pains, to hypoglycaemic episode, to a likely bone malignancy. Recognising the likely bone cancer in a 7-year old boy was particularly moving. This child needed a haematologist and costly intervention. How on earth will this really happen – where is there a specialist hospital unit? Will the Lebanese doctor discriminate against the Syrian? Who will transport the child back and forth? Who will cover the costs? Who will look after the immunocompromised child if chemotherapy is the treatment of choicer? Is it too late anyway? These were all the kinds of questions one reflects on, and the unknowns are heart breaking.

Making a diagnosis is always a game of probability, but never really more so than in this resource limited setting, where health literacy of patients was minimal and gathering a good history was challenging even with translators. Attention was often diverted onto their painful stories of loss and despair in this prolonged war with no end in sight. The refugees just want to go back to Syria, the land where they grew up, where they had a living, where they had good memories with their families and friends, and where they were individuals as opposed to ‘refugees’. They certainly do not want to make a trip to Europe as far as possible.

Various pressures were on us and it is emotionally, physically and logistically intense – seeing as many people as wanted to be seen, being in a completely unfamiliar clinical setting where the concept of privacy in a medical consultation is non-existent, knowing that unless someone is life-threateningly ill you wanted to avoid hospital because patients knew that it was chargeable and would be reluctant to go. No one has money, and dignity is dying out fast.

There were some just excited by the opportunity to see some new faces in their camp. We knew they were not sick and they knew they were not sick but we accepted this and made a non-verbal deal; We would examine them and show off the stethoscope and they wouldn’t spend too long pretending to have a problem with every organ system. These sorts of cases made us both reflect on a question one inevitably has at the back of their mind but we didn’t dare ask for fear of the answer – how much of a medical difference am I truly making? – but we realised that we don’t need to answer this question because there was no doubt that the presence of a doctor to show care and provide reassurance without asking for anything in return was worth gold. It gave back some dignity, reminded these innocent victims that they are humans and that the world cares for them. They are not forgotten despite their isolation behind white plastic tent sheets labeled with the blue, bold letters ‘UNHCR’.

The Affordable Care Act and USA Healthcare: Reaping the Whirlwind

image1Professor John Frey III is now retired from the University of Wisconsin Department of Family Medicine and Community Health but is still an active teacher, research collaborator, journal editor and ‘faculty whisperer’ about career transitions at all stages of professional life (a free service but you have to buy lunch). He lives most of the year in Santa Fe New Mexico but also part time Madison Wisconsin.

United States presidential elections are ridiculously expensive, far too drawn out, and provide an enormous amount of money for the media consultants to try to convince voters – or more likely scare them – into one position to the other. It is hard to imagine what the initial Republican Clown Car full of candidates must have looked like to the rest of the world. Culling them to a single individual has not helped all that much. Why those who suffer adverse effects from social determinants of health such as poverty, social isolation, family dissolution and low educational achievement continue to vote against their own interests and are attracted to a jingoist real estate developer and ‘small government’ libertarians has been and will be a subject of continuing analysis. Twentieth century history had lots of examples of dangerous demagoguery and likely so will the 21st.

The current situation seems to say “experience and ideas and policy don’t matter, only generalized anger”. Health care always comes up in the Republican debates as “get rid of Obamacare” as I have mentioned previously, with nothing to replace it.[1] Donald Trump infuriates the Republicans by not following the party line on health care and seemingly wants not only to keep the Affordable Care Act (ACA) but improve it in some way that he seems reluctant to describe. But Trump’s daily policy swings assure only that whatever he says he would do will likely turn out to be something else. Health care is more central in the Democratic duo, framed as a ‘pragmatist’ who can get improvements to the Affordable Care Act done versus an ‘idealist’ who advocates a national health system run by government. Having worked hard to help create two Democratic Pyrrhic victories – Eugene McCarthy in 1968 which helped elect Richard Nixon and George McGovern in 1972 which assured a repeat victory by Nixon – I personally am not anxious to stick to the purity of progressive beliefs and bring the world President Trump. Despite different visions of progress in health care, there has been movement, with Secretary Clinton suggesting permitting some people who are still working to enroll in Medicare – the program for elderly and disabled – as an addition to the ACA.

Meanwhile, the ACA moves on to insure more and more people, with the percentage of uninsured now at its lowest point in history. Young people were supposed to be the low risk participants that would offset the high risk pool, and that has happened to a great extent, although not at the levels that the government had hoped. To their credit, young people realize that having health insurance actually frees them to experiment with jobs and careers that don’t carry health benefits. As a result they are busier than ever with entrepreneurial startups and small businesses which are the life blood of society. Not tying health insurance to a job has had a positive effect on what has been labeled the ‘gig economy’ – freelancing and session work controlled by the person rather than the company. If an insured young person in the gig economy breaks a leg, it won’t mean that they have to go live with their parents because they are bankrupt. There has also not been the predicted disconnect between work-related health care as a benefit which has been the foundation of US health insurance. Companies still offer it to most employees, in part because it is a large tax deduction that industry does not want to lose and also because there is renewed competition for workers as the economy speeds up. Private coverage was declining before the ACA was passed but appears to have leveled off. While a substantial victory for the forces of good, the ACA has exposed other problems with the way Americans think about health care and have infused our culture since the mid-20th century.

Two historic cultural problems:

Insurance companies are our friends and protectors

The reforms that had led to a five year leveling off of the cost of health care in the US are now starting to be threatened by two themes that are deeply ingrained in the US psyche: first, the belief that private insurance rather than the government works in the best interests of the people and, second, that getting something for ‘free’ will create an overuse of health services by patients. These two beliefs were sowed in the wind of public opinion back in the mid-20th Century and now the country is reaping the whirlwind. While the rest of the economically developed world adapts health systems to a changing society, the US remains stuck in 75 year old arguments.

The fact that private insurance companies compensate hospitals and physicians and pay for drugs for claims submitted to Medicare always comes as a surprise to the public – and sometimes to physician colleagues. Private insurance companies are contracted as ‘fiscal intermediaries’ for state and federal governments to manage programs like Medicare and Medicaid, for the elderly and the poor. The public has the image of an office building of government bureaucrats in green eyeshades and quill pens in Washington writing checks for over a trillion dollars to health care providers. But these contracts with private insurers limit the percentage of management fees the insurance companies can charge. Allowing ‘only’ a 4% overhead charge to manage Medicare may seem restrictive compared to the up to 20% overhead allowed by the ACA that companies can charge for private plans for the ironically titled ‘medical-loss ratio’ which treats payments for medical care as a ‘loss’ to insurance companies. But because there are more than 55 million of us on Medicare and growing daily, the billions of dollars that insurance companies get yearly to manage a straightforward program with minimal complexity is not so shabby.  But, despite a great deal of research to the contrary,  the public still feels that private insurance companies with high overheads and deceptive practices deliver better quality care than government programs. The Republican Party takes advantage of that belief to denigrate Medicare and Medicaid and the ACA and threaten to turn those programs to the private sector. (Sound familiar?) Not coincidentally the Republicans receive a great deal of money from insurance companies and present no alternative to the ACA other than ‘trust the insurance companies rather than the government’.

On the Democratic side, Senator Sanders picks up on one element of the progressive agenda which started in the late 1940s with President Truman and dwells on the ‘single payer’ mantra which, like so many other sound bites, is not really understood even by those who advocate for it.[2] The problem with ‘single payer’ is that, unless there is a rapid realignment of payment toward primary care and a change from the fee-for-service, production model which dominates US health care, it really would rapidly bankrupt the system. Ontario, in the Canadian single payer system, has moved most of its primary care to a capitated model and salaried service in part because of the strains of fee-for-service care but even with that change, continues to struggle with the right governance and accountability.[3]

In many ways, the whole debate for this presidential election threatens to be a war of sound bites, ‘single payer’ on the left vs. ‘end Obamacare’ on the right with neither party having the skills or the American people having the patience to actually understand what those phrases mean. And no one is discussing the 30 million Americans – the young, the low income families, and the undocumented workers who remain without health insurance.   While ‘universal coverage’ may mean what it says, it may have an asterisk next to it saying “except the 11 million undocumented workers who live here now and who we would like to ignore”. No one wants to have a serious conversation about immigrants at any level.

Being insured yet with ‘out of pocket’ expenses:

I have a photo from a collection from the National Archives of photos taken during the 1930s that shows a general practitioner sitting at his desk with a stern look on his face and a sign that reads ‘Consultations: Cash Only’. While one might be amused by the 80 year old photo, offices and hospitals are more subtle about it now but still demand payment from the patient, even if the patient has health insurance. ‘Co-pay’ and ‘deductible’ are the terms used these days for the portion of the bill patients must pay and are among the more maddening aspects of US health economics. Patients who have to make frequent visits may have $40 charges for each visit in addition to their insurance and so patients with chronic diseases which require frequent monitoring can quickly run up bills that keep them away even though they are ‘insured’. Drug costs are another example. I am on an anticoagulant for which I had a ‘co-pay’ of $15/month for the past year but my most recent refill said I had to pay $50/month for the same drug. The pharmacist gave me no reason and the health plan gave me no warning. All insurance products carry what is termed ‘deductibles’ which is the amount of money patients must pay before the insurance actually pays. The tiers of the ACA have decreasing deductibles with increasing cost of overall insurance. Patients still roll the dice when they are ‘covered’. A recent study reported that two thirds of Americans could not cover a $500 emergency and health insurance deductibles are ‘limited’ to $6850 under the least expensive plan in the ACA market! Such reliably conservative sources as the Wall Street Journal and Forbes have written about how the cost of health care for the average family is rising, even as more people gain insurance, and this cost is creating delays in getting care or receiving appropriate preventive screening. Bankruptcy from lack of insurance is being replaced by bankruptcy from deductibles. What is going on??!!

Underlying all this is the peculiar US cultural belief that if you get something for nothing, you will both over use the service and not value it. When, in the 1980s,  Health Maintenance Organizations (HMOs) made it possible for visits for preventive care and chronic illness to be free, the use of services saw an 18 month uptick but then settled into a predictable pattern of use. Nevertheless, the country has been furiously backpedaling away from the idea of free-at-the-point-of-service care, adding co-pays and other costs to patients to try to steer them away from, for example, emergency rooms or certain medications. It reminds one of the airline industry where what appear to be inexpensive trips suddenly become expensive because of add ons like paying for bags, paying for a seat with leg room, or paying to get on early, all of which add billions of dollars of revenue that was not planned by travelers.

So there continues to be a dance that insurance companies, employers, state and federal government and citizens engage in that keeps health insurance from being simple to understand and that gives energy to the call for ‘single payer’ without having to deal with the insurance companies and their deductibles. The problem with that approach, sadly, is that the largest single component of the US Gross Domestic Product is unlikely to go through a radical change without resistance from those who stand to lose – including doctors, hospitals, Pharma and insurance companies. And if the NHS, with a long history of being widely accepted as the way to do medical care right, continues to struggle with history, economics and a changing world, one can imagine what lies ahead for the Affordable Care Act, which the Republican congress wants to undermine rather than fix.

A colleague, Paul Gordon MD MPH, a Professor of Family Medicine at the University of Arizona, is on sabbatical bicycling across the United States listening in small communities to people’s opinions and thoughts about Obamacare and writing and recording these stories. It is literally a ground level view of what is happening. (You can read Paul’s stories on his blog: https://bikelisteningtour.wordpress.com/ ) He reports the ambivalence and lack of clarity about the ACA that shows how far the country has to go to get it right. However, the percentage of people who see the ACA as positive is climbing and the percentage of those who are negative is dropping and the lines are likely to cross with the next presidency. But that may not happen if the forces of deception, greed and world class dissembling continue to dominate US politics. Paul Starr’s opening line from his landmark book on the history of American medicine, “the dream of reason did not take power into account” summarizes what lies ahead whatever happens in the US elections.[4] Perhaps a corollary to Starr’s comment is that the dream of reason did not take mindless demagoguery into account, either.

Footnotes

[1] Frey JJ 3rd. Is Obamacare working? Br J Gen Pract. 2014 Jul;64(624):360-1. doi: 10.3399/bjgp14X680653.

[2] Oberlander J. The Virtues and Vices of Single-Payer Health Care. N Engl J Med.2016 Apr 14;374(15):1401-3.

[3] Marchildon GP, Hutchison B.  Primary care in Ontario, Canada: New proposals after 15 years of reform. Health Policy. 2016 Apr 23. pii: S0168-8510(16)30087-2. [Epub ahead of print]

[4] Starr P. The Social Transformation of American Medicine. 1982. p 3. Basic Book Inc. New York

Desperately seeking Plato

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

file0001075296394We were in Athens with a couple of hours to kill. Acropolised out, too early for Ouzo. We had seen Socrates’ jail cell (almost certainly apocryphal).  We had seen the remains of Aristotle’s Lyceum, lovingly excavated. We had felt the weight of Pericles and the genius of Phidias. So we had a chance to check out an old rumour that the site of Plato’s academy was now marked only by a Texaco garage. (We had just found a Lidl on the site of the battle of Marathon, so who knows?) There it was on the map, “Plato’s Academy Archeological Park”, just a few miles out from the centre of Athens.

According to Alfred North Whitehead all philosophy is a series of footnotes to Plato. When my out of hours driver had been mind blown by the illusory world of “The Matrix”. I explained that this came from a two thousand year old thought experiment that we call Plato’s Cave. Suddenly my driver was interested in philosophy. Plato tackled the problems of perception and how we can (or cannot) know reality long before Descartes or Kant. He and a few mates created western thinking.

So we asked a taxi driver, gnarled as an ancient olive tree, to take us to Plato’s Academy. He looked confused. “But there’s nothing there.” We say that’s OK, we would just like to see the site and take some pictures. “Well, I haven’t been there for years” he said. We offer him our map, which he declines. We leave the tourist trail, driving through run down streets, the never ending layers of graffiti resembling Jackson Pollock’s stream of consciousness. A corner shop displays its stock of “Essex” washing powder, the finest goods on offer.

Unfortunately we have chosen a taxi driver straight from My Big Fat Greek Wedding. He explained all of Greek history with a running commentary on language and civilization, demonstrating exactly What The Greeks Did For Us, which by a remarkable coincidence turned out to be absolutely everything. Triangulating with what I already knew I reckoned about a third was approximately true, albeit exaggerated. We decided not to mention Lord Elgin.

We reached the area on the map. There was a post apocalyptic park of sorts. A couple of adjacent areas of worn and scrappy grass with a few dejected trees were surrounded by railings within what looked like a condemned South London Council Estate. We drove around randomly looking for something the driver recognized. There were no signs, no indication of an archeological site (surely the only square mile in Athens so deprived). The driver stopped to exchange enquiries with puzzled locals, none of who had ever heard of Plato and all of whom clearly wondered if we needed strong psychotropics.

We settled for jumping out of the taxi and taking random photos of the grass, concentrating on the occasional stone wall, which may or may not have been more than fifty years old. The driver became excited by some stone columns in a lock up yard, but on close inspection they were recent architectural salvage. However we found some overgrown stone ruins behind yet another fence, inaccessible and unlabeled. We declared these to be the ruins of Plato’s Academy, and duly photographed the hell out of them.

Driving off through the dystopian labyrinth we found a structure resembling a grey shipping container with the sign “Plato’s Academy Digital Museum”. It was locked. We walked round and found two elderly Greeks. “Come back tomorrow” they advised. A good suggestion except that by then we would be in France.

We drove back. So many shabby streets. We had not even found the Texaco garage. We heard more dodgy political theory than the whole of Plato’s Republic. How was it that this city, so full of ruins (and so full of itself) could not remember its greatest philosopher? We could find no trace of Plato. Not even a cave.

We sped back towards our hotel. Time for Ouzo and another view of the Acropolis.

Visit bjgp.org to find and read David’s series ‘An A-Z of medical philosophy’. 

GP in crisis: how does European family medicine compare?

IMG_0277Mary McCarthy is a GP in Shrewsbury., She is on the GPC and is interested in comparative health systems. She is the BMA rep to UEMO.

UEMO (Union Européenne des Médecins Omnipraticiens) represents GPs in 26 European member states. It develops policy and projects to support family medicine and to share best practice. It also provides an opportunity to look at other health systems and to learn from them, studying alternative ways of working and investigating ideas that may help with UK general practice.

Earlier this year, a questionnaire was circulated by the UK delegation that asked about workload pressures in the differing EU member states. A total of 25 states replied (Malta gave two answers for their public and their private health care systems) and although the data set is incomplete, it still makes interesting reading and an overview of the findings is presented here.

Different models, different responsibilities

Not all countries have registered lists of patients. Often it divides, as it does in the Irish Republic, into those that are covered by a means-tested state-led system who have to be registered to take advantage of the financial benefits, and those who pay privately for health care, either through an insurance-based system or through their own pocket.

Sometimes, as in France, there is no requirement to register but because insurance companies offer incentives, 90% of patients do.

In Europe, Family Doctors may act as gate-keepers, as they do in the UK, or as signposts where they just act as a conduit to secondary care. The second course means that they do not deal with chronic disease management so do not have the pressures that the increasing shift to general practice of disease management that used to be dealt with in hospital clinics. In many EU states, children are seen by paediatricians not by GPs and gynaecological problems are referred for examination and investigation to gynaecologists.

Elderly people who are resident in nursing homes may be under the care of Community Physicians or, as in Holland, Nursing Home Doctors. Mental illness may be referred directly to secondary care.

Workload and practice

List sizes vary from 600 per GP in Belgium to 3,500 per GP in Turkey and consultation rates per GP vary from 10 a day to 50 a day. This figure is confused by the fact that some replies counted telephone consultations as well where other nations just rated face-to-face consultations.

Group practices are gradually becoming the norm throughout Europe, though Belgium still has only 3% of practices with more than one doctor. In Italy roughly 50% of practices are group practices and in the Netherlands about 75%. The UK is still far ahead with more than 90% of practices being group practices. E also have larger groups of doctors. In much of Europe practices have 2-3 doctors as opposed to our average of 6-7.

Most have list sizes of 1600 or lower and that I itself makes for a less stressful environment. The working day generally approaches the normal for the working population of the country being 8 hours a day or fewer – in the Danish system GP surgeries close at 4 pm on Monday to Thursday and at 2 pm on Friday. The health of the Danish population does not seem to be adversely affected by this restriction of GP hours of access. However despite this 76% of EU nations feel that general practice workload is unreasonable and unsustainable.

If the nations that think the workload in general practice is reasonable are examined, they tend to have some factors in common. They have a normal working day – that is, eigth hours or fewer and mostly have a list size of 1600 or fewer per GP. They are more likely to have longer consultations and, of course, have easier access into secondary care beds. However, the factor that seems to be the most important is the number of patient consultations per doctor per day.

Consultation length and duration

Most nations have 15 minute consultations with the Scandinavian countries veering towards 20-25 minutes. Those nations with 25 consultations or less a day find general practice manageable. Those nations who either have telephone consultations or face-to-face consultations that exceed 25 patient contacts a day per doctor find general practice unsustainable. They have problems in both retaining GPs and in recruiting newly qualified doctors to a GP training programme.

Home visits

Most do little home visiting – though this may be due to the greater availability of beds in European countries. The UK has the lowest bed numbers per 100,000 population in Europe with France having double the beds and Germany three times as many. This means that admission of sick patients is more or less the norm, rather tha, as in the UK, making huge efforts to keep patients out of hospital.

Summary

A profession under stress is a profession at risk. Maybe the answer is simply to reduce access to EU levels; to restrict doctor-patient contacts, both telephone and face-to-face consultations, to fewer than 25 a day. It may be possible to divert some demands to pharmacists, nurses or other health professionals. It may be possible to educate the public to self-care, at least for minor illnesses.

General practitioners are expensive and time-consuming to train. It would be sensible to use their skills carefully.