Dr Andrew Binns looks at the chequered history of after hours home visits by Australian GPs, and the current scheme’s uncertain future.
I arrived in this region nearly four decades ago, setting up my own solo practice in April 1979 and some years later gained an associate to share the workload. A major factor in encouraging more cooperation with colleagues was the need to provide after-hours care for our patients.
The challenge was to balance this commitment with family life, including factoring in holidays, plus the demands and expenses that come with running a practice to the level expected by patients and the various regulatory bodies.
As the years passed it became harder and we established a roster for sharing after-hours calls. This included obstetrics cover for some relevantly trained practitioners, including myself. However, even a three-practice amalgamation did not solve the burden of after-hours care provision, so we began to cooperate with other neighbouring practices to further share and manage the workload.
There were numerous supporting schemes through the evolving NRDGP, NRGPN and later the NCML. These worked to help us balance the competing demands of family life and work. But after a political change in Canberra and the establishment of Primary Health Networks the incentive funding to provide an after-hours service radically changed.
This signaled the advent of after-hours deputizing, bulk billing home visit services run by corporate entities. Some non-GP doctors were also employed in these services.
Not surprisingly, this has proven to be somewhat of a winner for patients who only have to ring to get home-service medical care that is bulk billed. By eliminating a gap fee for those who cannot afford one, this scheme provides no-cost access to after-hours medical care that was previously not available without attending an emergency department.
Those GPs who were previously providing after-hours service could pull back a bit and do less after hours consulting, while still providing a phone service, as well as practice visits, nursing home or home visits if necessary for genuine emergencies.
The latest arrangements have begun to alarm the Federal Government, which is now concerned at the huge cost blow-out for providing an additional service underwritten by Medicare. There is also concern that not all after hours visits are for true emergencies but rather for convenience in dealing with routine health matters.
A much-vaunted justification for this financial commitment was that it would reduce the escalating number of Accident and Emergency presentations, which are even more expensive than primary level care.
However there appears not to have been a reduction in hospital presentations. This apparent failure of the home-visits scheme is of mounting concern to Federal and State health funders, who are responsible for the clinical staffing of public hospitals where after-hours demands are continuing to rise, especially with the regular spike in winter.
So where are we now with this ongoing and complex matter?
As reported in GPSpeak, the MBS Review Taskforce has proposed that GPs who normally work in-hours but are providing urgent after-hours services will still be able to claim the larger Medicare item fees for after-hours attendances. Under such a change, doctors working for corporate deputising services will be limited to billing Medicare for non urgent consults, which is a much lesser fee. This draft report has gained the support of the AMA and RACGP.
However there are many headwinds for the Government in putting these measures into place.
The National Association of Medical Deputising Services will fight to save the business model that underpins them, with some questioning of the research that has led to the conclusion about the number of A&E visits not diminishing.
The current arrangement may have some personal advantages for GPs who provide comprehensive in and out-of-hours services. On a recent weekend when on after-hours duty, I received only a single emergency call. Last winter, under previous arrangements, I would have seen about 20 patients at my surgery, with receptionist support.
But the government, i.e. the Australian taxpayer, is footing a hefty bill to achieve a result that is not the main reason for the scheme, and cost is only one of the challenges. The stakes are high and many competing interests are at play, with politics and health economics being key factors in the mix.
When decisions are finally made, it will be fascinating to see the responses from the deputising services lobby, the medical bodies and of course the general community whose interest in the topic is yet to be fully aroused.
