Second and third rules of GP vax club

Now there is devil in the detail of the GP vaccine rollout, how do GPs think they are going to cope with what is clearly going to be a very messy process?

---

Last time we did this story (just two weeks ago) we made you read to the end of the story to get the first rule of GP vax club. As you should be expecting, the second rule of GP vax club is the same as first rule of GP vax club. Which is: “You’re on your own.”

Like you didn’t already know that. But before we get to rule three, it’s probably an important reinforcement of the situation unfolding between the primary care sector, the federal government, the key politicians and their political imperatives, the state governments, and, perhaps, the major GP medical college in the country.

Which brings us to the third rule, which, in the footsteps of Tyler Durden, isn’t actually the same as rules one and two, but is probably as important.

Two weeks ago we published a survey of GPs who were asked their view on how they felt about the economics and “government love” (maybe read management) around the vaccine rollout, given how random the information and process had been to that point.

The key finding in that survey was that nearly 70% of GPs were somewhat confused over what was happening and thought that they would lose money, or at least weren’t sure if they would make any money. The bottom line of the survey not withstanding was that GPs wanted to look after their patients and most were going to have a go at vaccinating anyway.

That survey was after GPs got their notice saying their EOI had been accepted but before they got their detailed starting pack, including proposed start timing, booking protocols, supply protocols, and supply amounts and timing, i.e. some devil in the inevitable detail of a very complex operation.

We asked Healthed, which surveys GPs after each of its fortnightly clinical webcasts, to ask the same questions again in its PULSE survey this week to see if much had changed once the details of the rollout were clearer.

The results are below. The prior March 2 survey first, and below is this week’s March 16 survey results. Be careful as the questions are asked in different order in each week:

Two trends are immediately obvious in the results.

Firstly, on the key questions: we will subsidise government, we can’t do this properly, we will lose money, we aren’t confident we will be financially viable, GPs thought after they had the detail that it was worse than they previously thought. Notably, having most of the detail now, there was a big shift in GP practice owners accepting that they would lose money.

The second and more interesting trend is that, despite all of the above, the percentage of GPs who are now clear that they will take part despite all of the above downside, increased considerably.

This is the: “we love to not think too much about GPs day to day, we know we need them, but when you really have some data on how much they give back to the community, despite them being used as pawns by the government all the time, and not being paid properly, you really do have to love them”, data point, in case you were wondering.

So they have the detail on what is actually going to happen, it’s worse than they thought, and what do they do? Start doubling down. They just want to help their patients and be part of an important process.

This is a pretty important data point for many reasons.

But the reason that I’m going to discuss here isn’t one any GP is going to warm too.

It’s proof positive that the government can treat GPs mean and somehow still keep them keen. At least as things all stand now.

Did we really need any more evidence that GPs were getting increasingly put upon by the government to deliver in this vaccine process, and remain resilient in their determination to take as much as is thrown at them?

Here’s a little background detail of the past few weeks to help you decide.

The Department of Health knew this week that the vaccination process for GPs actually started in a week’s time, that it would be slow because there isn’t enough stock, delivery wasn’t tested and that there was no booking engine or system ready. It knew that that the process would likely have to be dealt with very judiciously to prevent more mayhem in GP practices given these basics.

We are going to go out on a limb here and say that when one of our Prime Minister’s minders came up with the idea of launching the GP program a week early, calling HealthDirect and ordering them to have the central directory portal up and running on Tuesday this week in time for a hastily organised press conference, that someone in DoH would have told this minder that it’s probably not such a great idea.

But political imperative wins in this day and age. After all, GPs have strong backs. They’ll manage (which they will).

So the button got pressed, no one checked down the line what would happen (or cared apparently), and the Health Minister held a media conference on Wednesday morning complete with (metaphorical) starting gun, but not armed with a few simple but vital messages for patients, like, there’s no means of booking yet, our central directory portal isn’t tested and might fall over (which it did), our central directory portal can’t point to any booking facilities because they aren’t ready, we don’t actually have much supply anyway (sort of an important omission) and so on, and on.

Essentially, without a meaningful attempt to warn the public that GPs simply weren’t set up yet, that the government still isn’t entirely sure on supply, and the supply we think we have is teensy-weensy compared with our media conference big bang message of we’re all go on the next 6.5 million Australians, many people in a long chain in government all the way up to the PM would have known that the media conference was likely going to create mayhem.

If that is denied by anyone in this chain, then that person would be admitting to being incompetent. Either way, it’s not a confidence inspiring picture for the GP community.

But we think that most GPs realise all this from their survey answers.

This isn’t going to go well, set the rigging for a big storm if you haven’t already, and keep your head down, it’s going to get rougher.

In case the DoH is upset with this assessment I should emphasise that my guess is some of their staff probably tried their best to let the minders and the pollies understand what might happen if politics took precedence and they went a week early and left out all the important detail. We think that, or that they might not have even been told about the press conference.

When the press conference was held it was a fact that HealthDirect, which was meant to have a central portal directory up which linked the relevant booking engines to the relevant GP practices, didn’t have the site complete and tested, because it was caught on the hop by the political process. So HealthDirect can’t be blamed here either. It, in fact, has pulled off a lot of difficult IT work in a very short amount of time.

As the press conference was taking place, the portal did manage to have the first batch of GP practices which were cleared to vaccinate up and listed, at least (although the list wasn’t entirely accurate), but there were no links to the booking engines because no one told the booking engines and they weren’t ready.

Because the press conference was so politically motivated, the message was primarily that we are starting next week, isn’t everything great with this roll out (no, we are way behind and everyone knows it), we love GPs (tick for that at least), they are ready to go (no they aren’t), get on and start booking stuff (no, don’t do that because no one told anyone anything down the line and nothing is ready to go!).

All the major booking engines that service GPs were working to a Monday deadline of the following week. None of them were told about the press conference either. HealthDirect couldn’t link anyone because the COVID vaccination modules of each booking engine vendor still were not ready.

You might think that this was pretty late for the booking engines, given the official start date was within a week. And it is, but they didn’t know what or how they were supposed be doing on the roll out until a few weeks ago when the DoH admitted in a national call with the Medical Software Industry Association (MSIA) it really had no idea that a centralised booking engine concept was always dumb idea (this time you can blame the DoH for not being good at its job) and that it would need to rethink everything and allow the commercial booking engines to take most of the load.

So the booking engines will have all performed a minor miracle if they are ready by Monday, which I’m told most will be.

Out of all this, on Wednesday we got most GP practices in the country flooded with calls from anxious and misinformed patients who weren’t able to use a booking engine to get their vaccine booking, because nothing was ready.

The collateral damage of a day of mayhem for GPs and their practices isn’t as bad as you might expect. We think maybe some receptionists would have resigned, and some may have gone on stress leave the next day.

Revenue wise, GPs wouldn’t have lost anything much as most are booked up a few days in advance these days (unless you are CBD or rural clinic), but in terms of patient’s assessment of their GP service, there might have been a fair bit of short term practice brand damage. Many patients wouldn’t have even made it through to reception, and when they did you can’t imagine they were that happy.

“Sorry Janet, we actually don’t have vaccine for three weeks (if then, fingers tightly crossed behind back), and then we only have 50 doses, so you might be lucky to get in then also, our booking system will be up in a few days, but maybe we should call you when we really know what is going on?”.

Most GPs now probably appreciate how messy this process is likely to get at least. It might be interesting to keep doing this same survey but add one more question: “Do you now regret agreeing to be one of the vaccinating practices?”.

So no thanks at all to that political minion who convinced all the relevant politicians to go ahead with a media conference a week too early, in the hope of deflecting some heat off the Christian Porter affair, and from the increasingly obvious fact that the October deadline to vaccinate everyone was always a pipe-dream.

No thank you also to the politicians who didn’t think much of the possible implications and agreed to go ahead.

Here’s some more mess you might want to plan for in a sort of ‘plan for the worst hope for the best’ type strategy (although the following by no means might be the worst that can now happen):

• Supply to the government’s deadlines is almost certainly going to be a large problem. We’ve heard that CSL is experiencing some hiccups, and Europe is likely to withhold more stock. The TGA still hasn’t approved local manufacturing for distribution either. Nothing at all can go wrong for it to work to the current timetable.
• The booking systems aren’t tested and they don’t talk to any of the government inventory systems, so inventory is going to be guesswork going forward for the government. See supply problem above.
• Patients are unfortunately getting more and more hesitant. The AZ vaccine and blood clotting is in the media and even when the numbers suggest at this stage that the AZ vaccine might actually have the interesting side effect of reducing blood clot episodes (the numbers are under population average so far), the media coverage is what it is. It makes everyone nervous. The upshot is that simple screening and eligibility electronically, and smooth patient throughput is likely to be disrupted quite a bit by more hesitant patients.
• The government was way too late to the important problems in the booking plan, one of the biggest being that if you haven’t got a unique patient ID system, and every booking engine talking to each other, then patients are going to panic and make multiple bookings to ensure they get vaccinated as early as possible. This occurred a lot last year with flu bookings when patients panicked because of COVID. It messed a lot of things up.
• The political process is very hot and unpredictable. The government is desperate for wins and distractions. What happened this week will likely happen again.
• Canberra is now talking about adding mass vax centres to the equation (probably to ameliorate the obvious October deadline miss), which will throw the economics for some practices even more out the window if you get one set up near you.
• Some big pharmacy chains are already on TV confusing the situation. One large chain advertised this week that all their pharmacists would have COVID vaccination and they also would have a walk in service. That feels like it might even be an illegal commercial given that pharmacists technically were only meant to have their EOI application notified today and pharmacy isn’t due to kick in for a couple of months. How did this chain know it was accepted before the official notification and who Oked a national TV ad for pharmacy vaccination clinics when GP vaccination has not even started?
• And then there is also the infamous unknown unknowns. What if data on the AZ vaccine does actually turn bad? (probably won’t happen, but hey, plan for the worst everyone).

As usual, I’m whining about a lot of things that people are getting wrong, and which can still go wrong, which can be unproductive and even depressing.

So let me introduce you to GP vax club’s third rule.

It’s a silver-lining rule in case you’re annoyed that I’m being too negative.

The rule is: “Leverage the crap out of all the attention that is being showered upon you in this time of uncertainty.”

It’s not actually a rule I came up with but it makes sense doesn’t it? And thanks to that person who came up with it (you know who you are).

It’s a “glass-half-full rule” not a “make-hay-while-the-sun-is-shining rule”, because, let’s be honest, the sun is definitely behind a thick bank of angry looking clouds for the foreseeable future as far as GPs are concerned in the vaccination rollout.

I’m not a “glass-half-full” person myself as I don’t believe in the logic that being optimistic makes things go better magically– it’s a ridiculous premise. Remember the book, The Secret?

But there is a lot of logic to planning carefully to optimise the one thing that is good about this mess – GPs are going to get a lot of media attention and will have more meaningful patient interactions per week than perhaps any time in history.

All the attention and media general practice is getting in this roll out and thinking carefully about how you can turn that to your practice’s advantage as best you can, both in branding terms, and in financial terms, is an opportunity at the end of the day.

For one thing, although the government is happy for you to take all the problems generated by poor upstream mismanagement of the message and process while it attempts to achieve political goals, it is generating a lot of incoming interest and calls to your practice. And the government is spruiking general practice at every turn. Minister Hunt has nothing but praise for the sector, which is great PR in the end. It’s hard to think of a time when general practice has been so universally recommended and praised by the government and media (and so poorly paid given so much public praise).

OK, it would have been nice to have had a bit of warning on something like what happened on Wednesday, so you could maybe be ready and leverage the situation as best you could, but at least we all know now how sudden and random things can get in this process.

If you’d known, you could have had a great hold message, and put something on your website. I would have loved to have written that for you:

“Hi there, we apologise you’ve been trying to get hold of us, but the government is slipping in the polls and held a media conference to announce the start of the second phase of the vaccination program a week early when nothing was actually ready. Here’s what you need to know though, everything will be OK … blah blah blah. We love you, as always.”

Imagine what a message like that might have done amortised across every practice in Australia on Wednesday.

For one thing it would have had more impact on the political power that GPs actually can wield using their tight patient relationships, by a factor of 10 than anything the RACGP has achieved in the last 10 years.

Note: the RACGP has been suspiciously complicit with the government in their messaging on this stuff up, which is along the lines of:

• Of course there will be issues at the start (not if you don’t let politics rule the process)
• “It’s a marathon not a sprint” (LOL, it was a sprint just a few weeks ago when we had to do it all by October).
• There’s no rush here after all (see above).

Which you could be annoyed at, but at least the RACGP is also on telly singing your praises. President, Dr Karen Price, is a good TV representation of a GP: calm, smart, well spoken and educated. All good PR as well.

You might prefer your president, of course, to damn the government to hell for putting you all in the toilet for a day or so for no good reason, and pointing out eloquently to the public that it wasn’t your fault, but – glass half full remember– but she’s still a good ambassador for brand GP and she’s getting lots of press opportunities to be that ambassador.

The important part of rule three is making sure you plan all you can to leverage every bit of the attention to optimise your practice brand and financials as much as you can.

There will be immediate and delayed impact of patient loyalty depending on how you manage and communicate a difficult journey for your patient, but if in the short term you do bend over and explain all that is going on, and make their journey a more comfortable one, even if you do lose money , the long term return for your practice in patient loyalty could be significant.

Lastly, there are practical immediate things you could do to make money with all the attention.

I’m not going to delve into the detail of this here because while there’s a lot that can be done – co-payment, hesitancy consults, and so on – getting the balance right so you won’t have the worry of getting a “nudge” letter one day, needs careful thought.

It’s a “do you want fries with that?” strategy that you could try to map out, being sure that you don’t annoy those pesky fellows at the PSR and DoH too much.

We are going to try to provide some more detail on this in next week’s Money and Medicine column – a sort of, ‘staying comfortably on the right side of the PSR penalty line guide to leveraging every vaccination candidate you have’.

Which reminds me, it looks like the DoH might have shifted just a little from their “nudge letters rule” thinking which had been focussed a fair bit around the idea that “a little bit of fear goes a long way”.

Last week the RACGP, for some reason, wanted to scare everyone with the idea that 30,000 GPs were in breach of telehealth rules and might be getting a note from the department when that was never going to happen.

We now know now that the DoH never had any intention of doing that and had done a lot of talking with all the relevant GP bodies to work out what would they could do, because clearly there had been some misunderstanding and they needed to communicate some message in some way in a difficult time.

The DoH very early in negotiations reduced the number of letters they wanted to send from around 9,700 to 740 and then 500. So they were listening to the GP colleges and the AMA. One thing they listened to was that scaring too many GPs who were about to start vaccinating the nation probably wasn’t such a great idea.

So kudous to all the colleges and the AMA for talking the DoH quickly down to 500 letters from at least 9,700.

But then ask yourself, why did the RACGP, knowing that the DoH only intended to send 500 letters to GPs, write an article a week ago, saying that they had been told by the DoH that up to 30,000 GPs were in breach of telehealth rules? If you already knew only 500 would be getting a letter, why even say 30,000 was ever even a possibility (it wasn’t) and risk scaring all your members?

The answer unfortunately seems to be that the college was playing games with their members and attempting to paint a picture of the big bad DoH coming in heavy with a threat to 30,000 GPs and then being talked off a cliff by the hard working RACGP leadership. So a big win for members by your college?

The DoH was more than reasonable in how they attempted to manage what must have been a delicate process. They gave the colleges and the AMA a lot of forewarning, and then listened to their arguments. They ended up deciding to send only 500 letters. Not 30,000 as the RACGP had written about in their newsletter.

The upshot is that the DoH is listening too and thinking a lot more carefully about their fear based approach to compliance – “nudge letters”

But what about the RACGP?

Why did they write an article implying that the DoH might be lining up as many as 30,000 GPs for some form of compliance activity when they knew all along that the number was 500?

See you next week.