In 1979, when I started in GP practice, some 80% of my patients presented with an acute problem. Now I estimate the same quantum has one or more chronic diseases. The Medibank scheme started in 1975 (it became Medicare under Hawke in 1984) and the standard consultation was described and given a monetary value.
The descriptor basically said take a history, examine the patient, investigate as appropriate, implement a management plan, provide appropriate preventive health care and document this record on the one or more presenting health- related issues.
Fair enough for a sore throat or ‘flu like’ presentation but what about the patient with one or more chronic diseases, who is likely to have multiple medications and many complex physical and/or psychological health issues?
The allotted consultation time of up to twenty minutes to manage all this often falls short.
There are virtually no chronic diseases where there is evidence to support resting.
It is true that the situation is getting worse because of the ageing population, however we also need to factor in the baby boom bulge – not just the abdominal girth issue but the population bulge.
This has resulted from the significant post-WW2 ‘populate or perish’ baby boom promoted by the government in the interests of the economy and defence. Then add in the immigration push that was promoted for the same reasons.
This all adds to the pressure and expectations of general practitioners as the gate keepers of the health system funded largely through the Medical Benefits Scheme. An acknowledgement of this compounding pressure has been the development of chronic disease systems that involve the team approach with allied health professionals as well as medical specialists.
But when it comes to preventive care the team is often giving out the same advice no matter what chronic disease presents. For example, there are virtually no chronic diseases where there is evidence to support resting.
On the contrary there is mounting evidence to support increased exercise, not just for the metabolic diseases but also for chronic diseases such as cancer and dementia. Research keeps coming in that supports exercise as being beneficial. Other lifestyle issues such as a good diet, adequate sleep, smoking cessation and alcohol moderation also rate highly as preventive health measures.
The so called share medical appointments (SMAs) or group visits provide the framework for improving efficiencies in patient education and empowerment for self management of their chronic disease(s).
SMAs involve a group of patients with chronic disease(s) - not necessarily the same - sitting in a talking circle with an allied health professional who provides facilitation for one and a half hours. A doctor comes in for one hour during that period to add weight to the advice on bringing about lifestyle change and providing motivation.
There can be a so-called “programmed SMA” for people with like illness, for example diabetes, chronic pain, obesity, or a more general group who can bring up any topic they like.
Currently, the GP time is often funded through the standard consultation for each person in the group and this is compatible with the current descriptor. There is no specific Medicare item number for GPs or allied health professionals for such groups.
SMAs complement one-to-one consultations and are different from purely educational sessions in that the GP’s presence adds clinical expertise as well as helping to motivate the group. Positive group dynamics are important and the facilitator is also a key to achieving this.
There is a need to find innovative ways to improve efficiencies for coping with the increasing demands of managing chronic and complex disease in general practice. Motivation for bringing about lifestyle change is vital for preventive health care, and in a standard consultation the need for diverse clinical input often outstrips the time available.
The baby boomer bulge and shared medical appointments -
Dr Andrew Binns at the NoRDocs Unconference, 30 June, 2018
