Is corporatisation of deputising services corrupting the after hours system?
The National Home Doctor Service ran into controversy last week after GPs hit social networks and medical newspapers, critical of the group spruiking its service via a series of TV advertisements.
According to some GPs, the National Home Doctor Service (NHDS) is artificially stimulating demand for emergency after-hours services. The NHDS is a network of doctors that provide bulk-billed after-hours medical care to patients in their homes and in aged-care facilities.
Key among the concerns of disgruntled doctors were that the ads would stimulate demand, especially for expensive after-hours items, and drive up costs to the healthcare system.
Some doctors claimed the NDHS was charging after-hours visits as urgent, when they weren’t. There were also claims that some NDHS doctors had advised patients to re-contact them through the service if they didn’t improve, in a manner that gave preference to NDHS over their local GP.
NHDS CEO Ben Keneally defended the advertising campaign, saying NHDS had received feedback that the ads were clearly supportive of general practice. Keneally also said their own research had shown that home visits lowered system costs by reducing ED presentations.
Keneally told The Medical Republic that the growth of urgent versus non-urgent items in the last five years had been reasonably small and steady. Urgent items had increased from 65% to 70% in that time, he said.
The data isn’t clear yet in Australia, although if the experience of the UK is anything to go by, it’s a very complex ecosystem of businesses chasing payment incentives, patient attitudes, which vary between socio-economic status, awareness and, importantly, acceptance or not from the local “in-hours” GP practices in a given region.
It is for the latter reason that many Primary Health Networks (PHNs) are attempting to work with groups such as NDHS to improve after-hours care in their regions.
Keneally said that NDHS doctors were allowed to recommend that a patient follow up with NDHS, but only where the patient might be at risk of requiring hospitalisation, and only when that patient needed help again in the same after-hours period. He said it was a “rare circumstance”.
Deputising has been around forever in one form or another, but until the last few years it has been a very localised, “mum and dad” type of business making most of its money from “subscriptions” by local regionally based practices who want to offer their patients a service but do not have the will nor resources to offer it.
GPs are sensitive to the issue of the corporate growth of such services for a few reasons: they stand to lose business to after-hours services based on convenience being subsidised by the government; they genuinely fear that over servicing after hours is going to suck the system dry of funds needed elsewhere; and there is a touch of guilt about how modern general practice is changing its image.
“When we use a deputising service we feel just a little bit dirty because we know that in an ideal world we should be doing it ourselves. We all want a life these days, though. Times are changing,” one GP told TMR.
About four years ago private equity worked out that a national offering could be made viable by underpinning such a service with technology platforms to make them efficient and modern management techniques, especially around teams and culture.
They also calculated that such a business with new efficiencies and volume would likely make a lot of money as they knew that with the past fragmented system the population awareness of such services was very low, and that they would likely be supported well by the government, which was looking for ways to improve accessibility to GP after-hours care and relieve pressure on EDs.
A key driver for services such as NDHS is the premise that most people still don’t know about them, and as a result end up going to an ED when they don’t need to. Hence the advertising campaign.
The question is (and what has underpinned the discomfort of many GPs in the last week): will the growth of these services actually decrease costs, or will they promote a very expensive taxpayer foray into subsidising patients who can’t be bothered to see their doctor in normal working hours?
The key issue is that the end user isn’t paying the premium to be seen after hours, the government is.
While it’s not yet clear what is causing the growth to start to skew towards urgent items, it is clear that the deputising services are growing at speed and will likely be a big business in the near term.
Keneally says the rate varies depending on the region.
“Adelaide and the Gold Coast have been growing at 5-10% per annum, while Sydney has been growing much faster, but off a much smaller base”, says Keneally of NDHS’s user base.
The authors of a paper released last week in the Australian Journal of Primary Health looking at after-hours services and commissioning by Primary Health Networks of such groups as NHDS, said that on average the sector was growing by 17%.
