Family Care Medical Services (Australia) Pty Ltd
"Providing world class after hours primary medical care”
Medical Directors and Service Governors:
Dr Beres Wenck M.B., B.S., F.A.M.A.	Principal Medical Director
Dr John Buckley M.B.,B.S., FRACGP, Dip. RACOG. 	Continuing Professional Development
& Training Medical Director
Dr David Preller M.B., B.S. FRACGP.	Medical Director (Brisbane)
Dr Trevor Beall M.B., B.S.	Medical Director (Sunshine Coast)
Dr Harry Ratnam L.L.M.R.C.P & Si	Medical Director (Ipswich)
Dr David Brand M.B., B.S., F.A.M.A.	Consultant Medical Advisor
Dr Joanna Tait M.B., B.S.	Medical Director
Hon. Mike Ahern Ba Agr Sc, FTSE, FQIMR	Independent Advisor

31/5/2005

Mr. Mike Woods Commissioner 
Productivity Commission PO Box 80
BELCONNEN ACT 2616

Dear Mr Woods

Thank you for the opportunity of meeting with you and your colleague, Ian Gibbs on Wednesday May 4 2005.

This submission addresses the issue of "the provision of out-of-hours service by General Practitioners adjacent to acute care hospitals" as part of your Health Workforce Research Study due to be completed by February 28 2006.

You will be aware that Family Care Medical Services is Australia's largest provider of After Hours Primary Medical Care Services. We provide after-hours home visits to the residents of the Sunshine Coast, Brisbane and Ipswich. We also run 3 co-located clinics at Caloundra Public Hospital, Caboolture Hospital and Logan Public Hospital. Each year Family Care Medical Services deals with 200,000 patient contacts of which approximately 70,000 are home visited, 30,000 seen in our after hours clinics with the remainder referred back to next day GP care.

We contend that in our Southern Queensland service coverage area (1,600,000 people) there is no evidence that public hospital emergency departments are over burdened by primary health care patients (category 4 & 5). Our view is confirmed by two sets of data:

i)	Queensland Health data on Emergency Department demand (by category) for all public hospitals in South-East Queensland.

ii)	Family Care Medical Services data on weekly patient attendances at each of its 3 co-located clinics. Our statistics show low patient demand during the week and moderate demand on weekends. Overall our co-located clinics are marginally economic to maintain due to low demand. Indeed present demand at the Logan After-Hours Primary Health Care Clinic is below an economic sustainable level

necessitating an extension of a Commonwealth Government Grant to allow the clinic more time to reach economic sustainability.

Our view is that South-East Queensland has a well functioning system of Commonwealth funded after hours care that balances universal home visiting access with strategically positioned co-located after hours clinics. Over 90% of all Family Care Medical Services contacts are bulk billed facilitating equity of access for patients (see our service and social charters at www.familycare.com.au )

Additionally various 24-hour Private Hospital Emergency Departments exist in SouthEast Queensland (Wesley, Saint Andrews, Mater Private, Holy Spirit (North-side) et al) that support FCMS home visits and FCMS clinics co-located at Public Hospitals.

We are aware that the argument has been made by State Government that allegedly poor levels of day time GP bulk billing services have encouraged primary care patients into Public Hospital Emergency Departments and, in turn, this has created "bed block". Further, that due to this "Commonwealth created" demand, the State Hospital system is unable to function effectively (i.e. our lack of performance is not our fault, its all due to the Commonwealth)

The counter argument made by various medical groups, including the College of Emergency Medicine, is that seriously ill patients (category 1, 2 and 3) are trapped in Emergency Departments awaiting the availability of a bed within the main public hospital and that these beds are taken up by chronically ill patients. Thus it is argued that significant under funding and poor productivity in State hospitals blocks patients leaving the ED and accessing a State hospital bed.

Our experience is that the latter contention is correct in South East Queensland.

We are, however, of the view that after hours primary medical care services (which, if functioning properly stop patients from attending Public Hospital Emergency Departments and instead encourage home care) are not uniform across metropolitan Australia. Some parts of metropolitan Australia (such as South East Queensland) have very good after hours services whilst others are next to non-existent, such as Western Sydney.

This explains why, in some parts of metropolitan Australia, Emergency Departments are over-attended by primary medical care patients that would normally be visited at home.

Why then do some parts of metropolitan Australia have good after hours primary medical care services whilst others do not? Is this a function of the funding available, industry competition, industry investment, a regulatory omission, and audit omission or are other factors responsible?

Our contention is that after hours primary medical care services can be dramatically improved in metropolitan Australia with no additional expenditure, very limited Executive effort, and possibly no additional legislation.

Our contention is that after hours primary medical care services can be dramatically improved in metropolitan Australia with no additional expenditure and very limited legislative effort.

Indeed the solution is relatively simple and will lead to progressive uniformity and improvement in after hours primary medical care services. Importantly the effect over time will be to reduce Public Hospital Emergency Department demand for category 4 and 5 attendances throughout metropolitan Australia.

1 a, The Commonwealth Government pays GP's a PIP payment for looking after their patients in the after hours primary medical care period. This payment exceeds $50,000,000.00 each year.

lb, Additionally, the Commonwealth remunerates doctors on a fee-for-service basis for patients seen in the after hours period.

1c, The Commonwealth also provides additional support to providers of After Hours Primary Medial Care such as Medical Deputising Services. Support includes access to workforce, from time to time capital grants and a range of other benefits.

Taken together, these payments and benefits should be sufficient to ensure that patients receive actual after hours primary medical care services in the defined after hours period (as is the case in Southern Queensland). When patients have access to high quality after hours primary medical care they do not go to the nearest public hospital Emergency Department. Instead they have their care at home, in after hours clinics or in 24 hour private hospital ED's.

2,  The Commonwealth regulatory environment that seeks to ensure patient access to After Hours Primary Medical Care remains sound, but deficient in several crucial parts. This is because it remains possible for some GPs to claim that they (or their agents) are providing after hours primary medical care where in fact they are not providing any care or are recommending patients attend a public hospital emergency departments. This allows the GP to claim the PIP for services allegedly rendered without the need to actually attend patients in the after hours period. The effect of such a regulatory oversight is to force patients away from GP home care and re-direct demand to public hospital Emergency Departments. Naturally such an outcome cost shifts from the Commonwealth funded CMBS to State funded hospitals.

3, Similar weaknesses in controls over Medical Deputising Services and after hours cooperatives allow "phantom services" to exist but not to provide important home visiting services to the community. Once again the effect is to force patients into Public Hospital Emergency Departments.

The solution to these matters is surprisingly simple. It is cost neutral. It can be accomplished with minimal administrative effort from the Commonwealth and it will largely resolve the problems of category 4 and 5 patients overusing metropolitan

Emergency Departments as it provides an already funded service to patients needing after hours primary medical care.

The principal to be followed is that Commonwealth funds expended on AHPMC should deliver actual AHPMC to the community.

PIP funds given to GPs for after hours primary medical care of patients, should only be given if that GP (or their agent) actually sees patients in the AHPMC period.

At the present time the provision of after hours primary medical care services is "controlled" via the Royal Australian College of General Practitioners (RACGP), who prepare "definitions" and "clinical standards". These definitions and standards are then used by accreditation bodies such as Australian General Practice Accreditation Limited (AGPAL) to accredit after hours medical services.

Access by a GP to the PIP is only possible if an accredition certificate is provided. In effect after hours medical services are self regulated by the medical profession through the RACGP with accreditation sub-contracted to private sector providers such as AGPAL and GPA.

In defence of the RACGP they are in a difficult situation.

On one hand their prime role is to establish clinical definitions and standards and additionally the Commonwealth has attached various financial and workforce benefits to these industry controls. The RACGP did not seek the role of unintended non-government regulator nor as the prime means not to ensure compliance with Commonwealth funding and community service delivery expectations.

However there exists a very simple means of addressing this issue. The solution is as follows:

1 The Royal Australia College of General Practitioners should ideally maintain its role in setting clinical definitions and standards for AHPMC services. The accreditation bodies should also audit to these standards. However the Commonwealth Government needs to one of two things:

(a) candidly advise the RACGP of its broader community service obligations and to demand that AHPMC definitions and standards be strengthened or,

(b) directly regulate AHPMC services under the Health Act through the use of definitions and audit standards .

2 In my view, the RACGP will not support direct regulation of AHPMC services as this would be regarded as a significant intrusion on the workings of the profession (see attached email).

3 Once the above issue is resolved, the Commonwealth (via the HIC) needs to audit the AHPMC PIP program so that it can be confident that service delivery benchmarks are being met (i.e. that GPs actually deliver real after hours services). This should include evidence that after hours services are actually being provided by GPs claiming the PIP. This too is simple to administer. Where a GP claims to be providing AHPMC services to his/her patients directly get the GP to sign a statutory declaration to that effect. The Commonwealth could contract to accreditation providers to spot audit practices from time to time in accordance with this requirement.

Definition and these matters will create a regulatory base-line for the provision of quality and accessible After Hours Primary Medical Care Services across metropolitan Australia.

In time this will allow after hour's providers the confidence to invest in improving services.

The effect will be to provide access to home based GP support in the after hours period leaving Public Health Emergency Departments responsible for urgent care of seriously ill patients (i.e. it will solve the after hours problem at the source, that being when the patient cannot be cared for at home and is then forced to visit the local public hospital).
Yours sincerely

Executive Chairman
Family Care Medical Services Ltd