Allied health is increasingly seen as a key player in primary health care but what does it mean for general practice?
By Eric Martin
The Strengthening Medicare Taskforce Report and this year’s Federal Budget spelt out the need for improving primary care and reviving Australia’s general practice services using allied health professionals.
Yet while funding has been allocated and the various doctor and allied health groups have been brought onboard, little has been revealed about the practical realities of how a more integrated general practice should operate, let alone the benefits for GPs.
Medical Forum caught up with paramedic and health care expert Professor David Reid, Associate Dean of Allied Health at ECU’s School of Medical and Health Sciences, to discuss the advantages and challenges facing GP clinics adopting the new model, as well as its impact on patients.
“The National Safety and Quality Standards put the patient at the centre of everything, but if it’s going to benefit practitioners, it’s going to benefit the patient,” Professor Reid said.
“Ideally you have an integrated system that may be co-located in one building, or in buildings next door to each other, which is, for example, what ECU has done at Yanchep and Wanneroo, where we have a GP service with external allied health who come in and provide clinics.
“ECU is developing a health centre in Yanchep where there is not a huge amount of health services and the nearest hospital, Joondalup, is miles away. The GP clinic will be followed by a second building for the health hub containing allied health services such as exercise physiology, with sonography potentially coming in one day a week to do scans.
“Imagine being able to say, ‘you actually don’t have to go all the way to Joondalup, they’re going to be here next Wednesday, and I’ll get I’ll get them to book you in for an assessment’.
“There is a clear benefit to GPs if you’ve got an integrated service and you can immediately refer somebody to a dietician, to the physio, to the speech pathologist, to the psychologist, or to the community paramedic based in the GP surgery, who does the home visits and the follow ups.”
Finding trusted professionals
Professor Reid explained that the other big factor for GPs was having confidence in knowing which practitioner to refer to.
“One of the biggest issues for many doctors is trusting the clinicians that you are referring your patients to – it is a double-edged sword. But if you have that close relationship with them, you can be confident when saying, ‘Yes, I trust this person, I know what they’re doing, and I know they provide good service’,” he said.
“Allied health is becoming more specialised as well. Physios, for example, also differ in their areas of expertise – all of them can deal with anything essentially – but if you need a highly specialised one, it helps if you can ask other physios who to approach.”
Professor Reid highlighted that one of the first questions to ask when examining the new model was ‘what is good health care?’
“Is it the fact that you go into hospital and get discharged without an adverse event? Or is it the fact that you did not need to go to hospital in the first
place, because you have some good preventative care that meant you could stay at home? Which is the better metric?” he asked.
“They are hard to measure, and they are hard to define, but I think that having these wraparound services will be good for patients in the long run and probably take pressure off GPs as well. The model is moving into preventative medicine and will stop people from needing to see their GP in the first place.
“We all have different needs at different times: an individual is not going to need a GP all the time, it might be that they need to see a physio for a few months and can complete this aspect of their treatment before moving on to the dietician or the specialist.”
The second question was, ‘how many people want to stay in their own home and get the care they need there?’
Smarter use of resources
“It is a big focus in nursing homes, but with an ageing population, what does it mean for people staying at home? Is there going to be an increased use of allied health? I think allied health can play a big part in saving GPs a physical visit in a lot of cases as well,” Professor Reid said.
“Especially by embracing technology such as the use of video consults and remote monitoring in aged care facilities, keeping track and touching base with the practice because somebody is sick or showing concerning symptoms.
“Nurses and paramedics know how to take the patient’s vital signs, they know the patient’s baseline, and they can electronically transmit it to the GP surgery or the care coordinator. There is the i-STAT machine where you can do basic bloods in the home, send it through and have a video consult.”
Professor Reid said it might be that the patient did not actually need clinical intervention, but it was important to look at their diet or get them to see a dentist.
It could be that this was their third fall in a week and the team knew that they needed a specialist to come in and look at what was needed to reduce the risk of falls.
“That is where the idea of allied health hubs and wraparound service can play a big part. Paying for a 15-minute consult is still a lot cheaper and a lot less resource intensive than paying $1250 for an ambulance trip to hospital as well as the cost of an ED presentation,” he said.
Enabling different clinicians to have efficient access to a patient’s medical records could also make a dramatic difference in terms of treatment options and outcomes.
“If you have a good wraparound service, there’s clear sharing of information and you have got up to date, accurate feedback on the patient,” Professor Reid said.
“You can look at what has been happening with the patient and go, ‘Okay, they’ve been doing X, Y and Z as the clinician, I need to do A, B and C.’
GPs still the linchpins
“The ability in an integrated system to share records means the dietician can see what has been happening with the patient’s blood pressure, they can see what the physio’s been doing, or what the OTs been doing, and equally, the GP can see what has been going on as well – this is a crucial feature of preventative healthcare.
“For example, if an individual suddenly has a spike in visits to his allied health practitioners, or they have suddenly seen the GP four times in the last two weeks, whereas in the last year they had seen the GP only once. That begs the question, is there something here that we need to put some extra support around for a few weeks or months?”
Professor Reid explained that he lived in the UK for eight years, where patients must be registered with a primary GP or practice.
GP as lead
“It meant that there was one source of truth, there was the longevity to build a solid history about that patient and that continuity of care, with the GP as the care lead for clinical staff, was crucial for patients over time, especially given the impact of chronic disease,” he said.
“Your GP has a long, established history of what has been happening in your life, and not just the clinical aspects but the social factors as well.
“There is a real challenge here as well in terms of the electronic medical records maintained within GP clinics. You may have your preferred GP within a clinic, but if they’re busy, or it’s something that you can see any doctor at the clinic for, then any GP should be able to access those records and continue treatment.
“Otherwise, you have got to try and draw it out of the patient and work out exactly what has happened.”
Similarly, many patients going into hospital were frustrated when they had to tell their story to the triage nurse, then tell the first doctor who saw them, then the second doctor and the nurse who came to look after them.
“There are stories about patients turning to clinicians and going, ‘This is the sixth time I have told this story. Don’t you talk to each other? Don’t you read the notes that the last person made?’
“There’s a level of relief when you have that primary care person coordinating your treatment, you don’t have to repeat yourself over and over again and that provides for better care.”
Professor Reid said the other consideration when co-locating allied with health professionals was that health care in general has become increasingly specialised, providing more focused opportunities for businesses to pursue.
“Even within a GP practice you will find that a doctor may have a special interest in paediatrics, for example, mental health or dermatology, and you need to decide what the business model is going to be,” he said.
“Will it focus on a particular area, such as sporting injuries or diabetes, or will it remain a generalist service? Is it a group of people working together as employees, or will they all be independent practitioners?
“The other issue is timing. For example, do you want your paediatric services running during the day in school hours, or are you better off running them in the evening after school? Could that be an opportunity to have evening sessional rooms, for instance.”
He said the success or failure of the initiative could come down to the efficient, flexible use of space.
“Space in capital cities is expensive and you need to maximise its use, which is a skill that practice managers and GPs will evolve over time,” Professor Reid said.
“It will also come down to professional relationships and breaking down professional barriers, with all clinicians being prepared to let go of something they potentially think is only theirs.
“At the end of the day, if you’re providing good care for your patients, it’s going to be of benefit to other healthcare professionals as well.”