Bush medicine: are the PHNs delivering?

Primary Health Networks were supposed to reboot rural healthcare. So why are rural doctors so disenchanted?

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Rural doctors remain sceptical about the Primary Health Networks created 18 months ago to drive better localised healthcare delivery in 31 regions across the country.

Even though one of the reasons for having them replace the 61 Medicare Locals was to offer a more GP-centric model of health planning and delivery, there is considerable uncertainty about what the new organisations actually do.

“They do a great job of looking after their branding – the font, the logo and the colour scheme, but they don’t have the same robust governance of content and functionality,” said Queensland GP Dr Michael Rice.

A major irritation for Dr Rice is that his PHN uses referral templates that are not compatible with general practice software.  With digital health supposed to be one of the focuses of the PHNs, it was beyond absurd that doctors have to fill out forms with a pencil and put them on a fax machine, he said.

“It’s like living in an episode of (satirical TV show) Utopia, with Rhonda and Carson in charge of the office.”

Dr Rice, who practices in the Gold Coast hinterland town of Beaudesert, observed that performance varied widely not only among the PHNs but also within single organisations, with pockets of excellence in staff and programs in some areas and “unnecessary complexities” and failings in others.

When the PHNs were established in mid 2015, after the Coalition dumped Labor’s Medicare Locals only a few years after they took over from the Divisions of General Practice, there was a sense of imperative to get it right on the third go.

Federal Health Minister Sussan Ley promised the new organisations would “reshape the delivery of primary healthcare across the nation” by improving frontline services and ensuring better integrated care between primary and acute care services.

A key selling point was that the new PHNs, guided by clinical committees led by local GPs, would put a regional focus on the six priority areas of mental health, Aboriginal and Torres Strait Islander health, population health, health workforce, eHealth, and aged care.

However, a recent survey by the Rural Doctors Association of Australia, with input from 56 doctors, reveals disenchantment on many of these counts.

“It is perceived that purchasing and commission arrangements are not working in some areas of health provision. How market failure is determined … is being voiced as a concern by many rural doctors,” delegates at last month’s Rural Medicine Australia conference were told.

“There also appears to be a lack of knowledge about PHN governance mechanisms, particularly in relation to representation on key committees including clinical councils.”

Doctors felt the PHNs didn’t understand the challenges of rural and remote practices and general practices as businesses, and where they did, it was perceived they lacked the resources to address the problems, RDAA senior policy and research officer Anita Rodriguez Macias said.

Many doctors also voiced concerns about the impact of the PHN’s service-commissioning role on health workforce recruitment and retention.

“Can vacancies be filled in a timely manner through the commissioning process? Some doctors have indicated that long-term vacancies exist in their PHN, particularly in the mental-health area, and are concerned that their patients need help now,” Ms Rodriguez Marcias said.

“Funding, or lack thereof, for mental-health services is seen as a really major issue.”

Some insight into tensions around mental health services in the bush emerged recently in northwestern NSW, where a public fight erupted over ATAPS commissioning by the Hunter New England Central Coast PHN, which took over a big stretch of country from Gosford to Moree covered previously by three MLs.

Psychologists Nell Gaff and Amanda Jefferys, based in Tamworth, told The Medical Republic that whereas the previous New England ML had given a lot of that work to “qualified clinicians”, the PHN had awarded the contracts to two providers who used only allied health staff.

As a result, four psychologists who had served the northwest from a practice in Gunnedah packed up and left the area.

“If you are in Moree or Narrabri, and you’re referred by your doctor because you can’t afford to pay a gap or it’s the only service in town, you might get a mental-health nurse or an OT or a provisional psychologist, someone who has not been trained to deal with the complexities of your condition,” Ms Gaff said.

“Nell and I cover a really huge area. But because of the pullback, it’s meant highly qualified psychologists, who were serving some of these towns, have moved away because they weren’t given work,” Ms Jefferys said. “It’s as if people who are marginalised for socioeconomic reasons don’t deserve a trained clinician.”

The pair said GPs were now referring more patients to them, some driving three hours for consultations while they were travelling similar distances to towns such as Wee Waa. They have appealed to politicians, including New England MP Barnaby Joyce, to address rural mental-health funding as a priority.

In response to their public campaign, Hunter New England Central Coast PHN chief executive Richard Nankervis published a letter in the Northern Daily Leader pointing out that the PHN’s mental-health funding had not been reduced and staff were working to “improve and evaluate the current mix of services”.

“On a value-for-money basis more mental-health services have been funded in the 2016-17 year than in 2014-16,” he said.

“The PHN is acutely aware that implementing a level of change, and developing our accountability for patient care and federal health funding over time, can have some initial negative impacts and perceptions,” Mr Nankervis said. “However … the PHN needs to fulfil its role of ensuring health funding is used effectively for the best outcomes in communities.”

Tight budgets are a constant refrain for PHNs, which serve as funding vehicles but cannot provide health services themselves.

Federal Health Department official Zoe Holdenson told Rural Medicine Australia delegates it was apparent that rural PHNs were looking to close service gaps, whereas urban ones were more focused on referral pathways and practice support.

“We could do all sorts of things in every region, but the point of PHNs is that they are able to prioritise what that community needs most through community consultation … through GP-led clinical committees,” she said, asking doctors to show patience.

“There is an intent to plan the use of money and make sure it is effective and addresses regional needs, and we understand the tension with service continuity and stakeholders waiting a long time for those services to deliver.”

Pattie Hudson, chief executive of Central Queensland Wide Bay Sunshine Coast PHN, another amalgamated giant, said budget constraints came with the need to be extra resourceful, and productive two-way relationships with GPs were essential.

“We know how busy our GPs are. They don’t want someone coming along that’s going to add another burden; they want something that will add value to their patient care and to their business,” she told delegates.

By working with training organisations to get education out to rural doctors, for example, the PHN staff were getting feedback on GPs’ needs. More than 80% of practices in the catchment were now in regular “engagement” with the PHN.

“It takes time,” Ms Hudson said. “The practice support officers go out to general practices and sometimes the door is slammed – like you’re a drug rep. They often say to me, they really don’t want us. I say, let’s refine this, what is the menu you are taking out? So they keep going.”

More than 40% of the PHN’s work was in education and support for GPs, practice managers and practice nurses, with programs including business development and the adoption of digital technology, Ms Hudson said.

A PHN-backed project being trialled at 11 local practices was the Health Pathways model for electronic referrals, allowing GPs to attach images and video and incorporating clinical terminology codes, such as SNOMED-CTAU or ICD-10, to improve data quality.

“I often say to my colleagues in hospital and health services and GPs, PHNs are the footsoldiers: we work with the community and gather the resources, then get together and say, how can we plan this better?” Ms Hudson said.

Victorian GP Dr Nola Maxfield, who chairs Gippsland PHN, one of the smaller bodies on the national PHN map, said the regional organisations should be actively explaining their programs to GPs and taking feedback. But where they didn’t, GPs should get involved.

“Probably there are a variety of governance models and some are working better than others.  They should come to you, but perhaps you need to be bashing on their door a bit,” she advised.

“I think, if I get agitated about something, I try to get on the board and get other GPs on the board.”

Until recently, Dr David Senior said his prime response to PHNs was to wish for a return to the old Divisions of General Practice. A practice principal in the South Australian town of Robe, with no hospital, Dr Senior had wanted to link into video teleconferencing with specialists in the state hospital system.

“The IT people at Country Health basically said it couldn’t be done because we weren’t employees,” the GP told The Medical Republic.

“Then, after speaking to cardiologists and psychiatrists who were supportive, I seemed to be getting somewhere, but it was going to cost an enormous amount of money to buy new equipment.”

Then someone suggested he get in touch with the PHN.

“Very quickly they made the arrangements so I can get into the system with the existing teleconference gear I’ve been using to contact private specialists – and they downloaded the software for me at no cost,” he said.

“This problem had been going on for years, and now, bang, it’s all happened.  A brilliant result.”