The wicked problem in general practice

The health landscape is becoming more fractured, patients and doctors more demanding. Hope lies in virtual solutions and better literacy.

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Lately I start my day with coffee, cereal, and AMA daily media briefings.

I ought to get a life, you say, and you’re possibly right, except I’m obsessed by hyperboles. “‘Dangerously constipated’ hospitals”, “Buck passing shows failure of national leadership”, “Medicare is friendless”, “Health system buckles under unbelievable stress”, “Perfect storm hits EDs”, “General practice is on life support”. I am a councillor for AMA Queensland these days and need to keep up with health politics.

Here in Australia, health is both big business and big politics. Politics is about leveraging money or status and it’s rarely bipartisan. Leaders made their mark by polarising the debate.

I was a medical student in Sydney during the 70s when university culture was counter-cultural; socialism was the new black. I was still basking in that socialistic afterglow in the late 80s when Bruce Shepherd AM was the president of AMA NSW before becoming federal AMA president. Through my university student lens, Shepherd sat to the right of Genghis Khan. The bombastic orthopaedic surgeon withdrew his orthopaedic mates from NSW public hospitals in a Machiavellian manoeuvre. It’s a classic strategy called creative perturbation.

I was trying to run a public hospital emergency department in outer-western Sydney and Shepherd’s power play made my job hell. We saw ramping of acute orthopaedic patients in ED comparable to our current ED ambulance ramping. Not a great way to win friends and influence people. It was hard to ignore the feeling that power, prestige, and money were at the core of the dispute.

My medical politics had been shaped by the legendary Fred Hollows, who managed to get the price down to affordable levels on intraocular lenses, thereby restoring eyesight to many in the developing world. Shepherd would later become a generous benefactor to charitable causes, but in the late 80s the contrast between missionary and mercenary was stark.

My stance towards the AMA dramatically changed when Brendon Nelson took over in 1993. He wore an earring, humility, and a welcoming smile. Finally, when Kerryn Phelps took the job in 2000, I became an AMA member, and threw myself into medical advocacy for the next 20 years. I then became a councillor in AMAQ – and gee whiz, was there a battle to fight.

Historically, our health system is reliant on primary care, mostly delivered by specialist general practitioners. Today’s media headlines teem with hyperboles declaring general practice to be on its death bed. How do you resuscitate general practice?  It’s a classic wicked problem.

Competitive tribalism

A wicked problem exists where any attempt to create a solution changes the way the problem is viewed. Wicked problems are resistant to traditional linear problem-solving methodologies, and they occur in the context of social complexity reflecting wide diversity between stakeholders.

At its core, the primary care GP problem is that while 80% of healthcare occurs in the community, only 15% of recent medical graduates are electing to enter specialist general practitioner training. These trainees constitute the pipeline to the future GPs required to provide the community healthcare. But who are the wider stakeholders? 

The community of patients are the largest stakeholder group. Their appetites for care are voracious, and their expectations are high. The community is geographically and socioeconomically diverse, and addressing this heterogeneity is the massive challenge.  The health landscape has changed owing to an ageing population, prolonged life through better healthcare, changing consumer demands for faster, more accessible healthcare and an increased focus on equity.

Taxpayers are the other stakeholder. They want value for money and low taxes.  

Doctors are another group, and we’re a mixed church. Because most of our professional incomes are derived from the public purse, we’re middle-class welfare recipients. We want job satisfaction, kudos, and more.

Stimulus variation is a major driver of a doctors’ career choice. Dread of “speed-dating” an endless conga-line of sick people from a sedentary position by a computer is what pushes some to choose interventionist careers. The general practitioners of old had stimulus variation but that’s been largely taken from them.

And then there is the public-private divide. The public sector docs (mainly on salary) get to knock heads with health bureaucrats and have no financial delegation. The private sector docs (mainly on fee for service) get to run a small business and have to pay office staff, practice nurses and themselves. Those on salary tend to work for the states, while those on fee for service “work”, for all intents and purposes, for the feds.

If the dominant narrative is that specialist general practitioners are a public resource, then perhaps they too should be on salary, regardless of public or private – like schoolteachers.

Allied health, pharmacists, nurses, and midwives are likewise stakeholders, keen to extract even more of the health budget via task substitution with or without clinical line accountability to doctors. These operate in both the public and the private space. If you’re getting a vision of competitive tribalism and tribes within tribes, welcome to my world view. 

And there are other stealth stakeholders. Health economists “understand” that they are the only ones who save lives. Shhh, don’t let on, but no one saves lives; at best we may prolong them! But there’s money to be made by prolonging them.

Add to the mix private health insurance/management companies. Add entrepreneurial medical corporates supplying universal bulk-billed care by importing international medical graduates. Then there’s non-government organisations, especially in the mental health and drug and alcohol space. And then there’s the health entrepreneurs. Nursing and aged care home providers, NDIS providers, purveyors of IT health solutions, IT support (think electronic medical records), Dr Google et al. Then there’s the “complementary” healthcare space – why are some happy to pay big bucks for a massage, while expecting their GP to bulk bill?

From cottage industry to Costco

Once upon a time, healthcare was a cottage industry. There were hostels, staffed by missionaries, which mainly supplied a haven and hospitality. During the industrial revolution, healthcare factories were built and called hospitals. There was still the family GP operating as a “corner store” administering medical care. Over the past 30 years, hospital casualty departments morphed into healthcare supermarkets. At the same time, we de-skilled GPs while undermining and devaluing the corner store.

The brand-new university hospitals are now so complex and care so fragmented that many patients need a nurse navigator to counter the real human dislocation within the hospital system.

Enough of the problems, what are the answers? Contrary to the myth, wicked problems do have solutions, though not all stakeholders will be beneficiaries.

We need smarter systems, smarter patients

One solution is to allow disruptive (or rogue) health innovations to blow our old models of care to smithereens. De-invest in bricks and mortar and move as much as we can to a virtual platform or hospital in the home. An online health kiosk accessible any time at the convenience of the patient could give advice based on AI and machine learning-generated algorithms. They can be linked to smart trackers (like Fitbits) to upload vital signs.

They could be also made to have inbuilt specs to improve the user’s health literacy. It’s a modern travesty, that in a new knowledge world, 60% of the Australian population are considered healthcare illiterate. Poor health literacy must surely be responsible for significant “wastage” in healthcare.

One reason for this is the traditional paternalism of healthcare. The very word patient comes from the concept that the person seeking care needed to wait while the professional healers weaved their magic. Personal engagement in the process was an anathema. Reverse that and end the waste. If this sounds patient-centred, you’re right, it is. 

Currently public health costs are assigned between two players, each quarrelling over turf. The argument for consolidation is growing louder. But what we don’t measure is the cost to the patients and the community as a whole. This is because we are bad at counting outcomes. Most of the KPIs are process indicators.

On the matter of measurement, I can now introduce my pet soapbox topic.

Digital health records have been plagued by scope creep. No longer purely a clinical record, they now have mandatory minimum data sets imposed by a plethora of interest groups remote to the clinical consultation. Data collection is designed to maximise billing practices, track clinician productivity, survey changing trends in population health, map process KPIs in the hope that they reliably measure patient outcomes etc.

After 30 years of ICT application, it is still a dalliance. Placing an ICT wrapper around the same-old-same-old will not cut it. We need to do things differently. This means one thing: we must take risks. The current risk-adverse climate must be reversed if we wish to move forward. Risk mitigation as it exists today is expensive, overly driven by politics, disempowering to clinicians and a barrier to change. 

Wicked problems are solvable, but only when we are prepared to make mistakes and are not obsessed with being perfect. There will be winners and losers. Let’s hope the winners are our patients.

By serendipity, Dr Omar Khorshid, the current president of the federal AMA, is an orthopaedic surgeon, with a considered macro view. These days I like orthopods. As an AMA member, I feel confident. Viva la revolucion. 

Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.