The best made plans of mice and men


Sometimes I cannot help but wonder whether Robert Burns, when he wrote his poem “to a mouse” in 1785, was perhaps thinking of a future government in a country far to the south of his native Scotland

RB

The Australian Government frequently and repeatedly tries to find new ways of doing things better. Occasionally these new ways are actually better but at other times one has to only shake your head in wonderment and bemusement at these schemes and who would be advising our leaders on the decisions they make. Our ivory tower academics or part-time GPs, who flit from conference to conference and hardly ever deal with the day to day coalface issues themselves, really the best people to advise our Government?

It is not hard to find examples of this and the first one that springs to mind is the NDIS.

dis

It is certainly true that disabled services prior to 2013 were a bit of a shambles. Some schemes worked very poorly but on the other hand some worked extremely well. Sometimes this would involve private funding and at other times it would be government funding either federal or state based.

In 2013 the federal government started to roll out the new scheme. The sales pitch was that it was consumer focused giving the consumer more choice and control over how and where support was provided and improved certainty on how they would receive this. This sounded fantastic but the devil, as usual, lies in the details.

For those of us working at the coalface the whole scheme was a mystery and two years later it remains a mystery in many ways. I tried to make sense of it and my understanding of the scheme is, rightly or wrongly, as follows:

Imagine we have a company that employs 100 people. It has a fixed budget and from that budget it needs to provide each employee with a pen and a desk. The company managed to do this for years and although it is perhaps not a top of the range pen or desk it did the job adequately.

Sadly some employees did not like their pens or desks and in order to maintain the peace the Human Resources Department decided that they would take the entire budget and equal this up in equal amounts for each employee. The employees were told to go and choose a pen and desk of their liking at a shop of their liking which they gladly accept and rushed out to go and purchase. The nearby stationery shops and furniture shops become aware of this and immediately increased their prices. The employees choose to buy top of the range fancy goldplated pens and mahogany desks.

The problems however soon started when those pens ran out of ink and there was no money left in the kitty to replace the expensive cartridges or when the mahogany desks needs special maintenance and there were no funds budgeted for this. Suddenly there was no more money and no productivity and very soon thereafter no more Company.

This might be a terrible oversimplification but in the two years that the NDIS has started its rollout there appears to be a multitude of new organisations that are now suddenly providing services to the disabled. We have the disabled and their family/carers being overwhelmed with choices and we have people making decisions on the care and services that may be good for them here and now but in the long term will prove to be extremely costly and not the best overall service that this person needs as opposed to wanting. Opportunist and entrepreneurs have realised that this is a pot of gold and hence we hear reports of NDIS budgets being massively overblown yet services are still as bad as they were.

Even more concerning are reports of well functioning units, run by various organisations, having to dismantle in preparation of being taken over by various NDIS funded schemes.

It may not be a politically correct statement but the consumer is not always right and what the consumer want is not always good for everybody.

The long-term survival of the system depends on it being able to care for all disabled people and not just a lucky few

 

Another example is the my aged care fiasco.

aged

As with disabled services the services for elderly patients were quite fragmented thus the Government decided to replace everything, all over Australia, with a single web Portal. This website was rolled out with very little, if any, attempt to involve medical practitioners, especially GPs, and despite our protestations about the risks and endangerment of our elderly patients it continues to be rolled out.

Horrible stories can be told from all over Australia but I can speak only for what we experience here in Canberra.

Until a few months ago if I needed to get an elderly patient assessed for possible admission to a nursing home or for other services at home it was a simple process of sending a fax to our local ACT government community health intake. Within 24 hours I received acknowledgement that the fax had been received and the patients would be assessed at home within the next 4 to 6 weeks

The new system is dramatically different.

I have an elderly lady who is no longer able to stay on her own and her children, who resides interstate, has arranged for her to be admitted to a nursing home closer to them. In order to get this process started she needed an assessment by our local Age Care Assessment Team. Unbeknown to us our local referral pathway has now also been switched over to the My Age Care team. I sent the usual referral to our local community intake number.

After no response for two weeks we sent another referral and called them. The only response was a voice message referring us to a 1300 number which I believe is based in Queensland. Out of desperation I elected to do another referral using the My Age Care website. The whole process was absolutely substandard in the security measures and the only reason that I risked the patient’s confidentiality being breached was my desperation to have her assessed. This third referral disappeared into the ether and all we had was a reference number.

All enquiries to our local unit was referred to the Queensland-based number and when we called that number they referred us back to the local unit.

This process went on for nearly a month and after multiple phone calls, emails we are now at a stage where she will hopefully be assessed sometime before Christmas.

A process that in the past would have taken only six or so weeks has now dragged on for nearly 2 1/2 months and we are still not sure when this patient will be definitely assessed.

This is no isolated story and GPs all over Australia are experiencing the same process. The same applies for simple things like getting incontinence pads for elderly patients or in fact any support for someone over 65 who is now considered an aged person and no longer eligible for NDIS or other similar schemes. It is now a totally impersonal referral to an anonymous unit based interstate and it takes weeks and months to get any sort of response and when a response is finally obtained it  is often totally inappropriate resulting in patient care being compromised.

 

This brings me to the recent announcement of a shakeup of the mental health system.

download

Readers would have noted that both the NDIS and My Aged Care schemes described above involved the government centralising services.

In a bizarre turnaround they have decided that the current reasonably centralised care of mental health services (although to be fair still very fragmented) will now be decentralised. They are not ploughing any new money into the system but funds are reallocated to what is known as the Primary Health Networks (PHN). The PHNs are the latest incarnation of what used to be known as the Divisions of General Practice. While the functional capacity of the PHNs all over Australia is varied (given the recent re-arrangement of their organisational structure) the main concern that I have lies in the advice that is being provided to the Government by their expert advisers.

Their main advisor appears to to be Prof Ian Hickie who is certainly a well respected Psychiatrist. Unfortunately it would appear that the Professor really does not have an idea where General Practice stands in regards to mental health management. In a recent article  Prof Hickie appears to be stating that he felt that small or solo GP clinics were unfit to be dealing with mental health issues. It shows an amazing lack of insight in the relationship that we as GPs have with our patients especially in smaller clinics.

The new scheme is not very clear (what’s new?) But what is clear is:

a. There will be no new funding in mental health

b. Existing funding will be managed by the PHNs and they will decide who     gets funded for the provision of mental health services. Preference will       be given to large multidisciplinary clinics.

That might sound quite straightforward but what are we supposed to do in a small clinic when, like yesterday, one of our doctors had three patients, in a row, present in a suicidal state. Should we just send them away and say, sorry we are not equipped to deal with this (as the prof would apparently have us), should we be transferring the patient to another GP clinic (where do we get the time and who pays us for spending hours doing this) or are we expected to just do all of this out of the goodness of our heart and not be funded at all for the work we do. This is difficult and time-consuming work and as things currently stand when we deal with such patients we work at a great financial loss our (three patients yesterday nearly an hour each) – as I understand the proposed new changes it would become near impossible to care for these presentations however we cannot simply show them the door when they rock up. Expecting us to act as charities will however end up in us failing to make ends meet and it will close more small clinics.

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