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AUSTRALIAN MEDICAL ASSOCIATION (WA)
Dr Nick Cooke has been involved in aged healthcare for more than 10 years – five of which saw him undertaking exclusively, visits to residential aged care facilities (RACF). Four months ago, however, he stopped visiting RACFs for a variety of reasons. These days, Dr Cooke is in private practice and visits just one residential care facility. Medicus asked Dr Cooke his views on the issues facing GPs with particular relevance to residential aged care.
Q. Why is it so difficult to attract GPs to the care of the elderly in RACFs?
It is a job, which is much easier to do if you do it full time. It is quite impossible to run a successful general practice and undertake nursing home visits. Even then, it is not adequately recompensed. Finally there is the perception nursing home visits translate into a lot of extra work that interrupts the normal day-to-day care of patients in a surgery. Demands from Pharmacy for prescriptions are the most time-consuming problem and also probably the most fraught with medico-legal consequences and enquiries from unhappy relatives. Dealing with pharmacy issues is the most common reason for stopping visiting nursing homes, and this was the reason in my case.
Q. Are younger doctors generally interested in geriatric medicine?
While they are not dismissive of geriatric medicine, I don’t think they have a particular interest in this field, as it’s a bit out of their comfort zone.
Q. What can the government do to improve attraction and retention of GPs to the care of the aged?
Remuneration levels, as they stand now, are inadequate. Come November 1, they are going to worsen given the current freeze on Medicare rebates. Remuneration fees also need to be put in place for non-patient face-to-face contact for activities such as repeating scrips or dealing with phone calls. There is a logical solution. As the fee paid per patient is reduced up to seven patients in one location, this means there is inadequate recompense for the extra time a GP has to spend in travelling to the RACF, setting up and then consulting. If the government is serious about improving GP remuneration, the fee per patient should be reduced up to three patients seen. That would increase the amount paid per patient and make it viable for the GP. The ability to provide telehealth on consultations is another contentious issue. At present Medicare only covers telehealth calls from a GP to a specialist – which is pointless. An experienced GP does not need to consult a Geriatrician, or a Palliative Care Medicine Specialist for most conditions. The provision of telehealth facilities, I believe, would be more useful for Registrars to consult with specialists or for nursing staff at the RACF to consult with the GP.
Q. Is there a good relationship between aged care operators and healthcare practitioners?
It would be to the advantage of both the doctor and the facility if management could better collaborate and cooperate with the GP. Some of the primary challenges faced by GPs consulting at RACFs are difficulty in accessing the internet and the lack of facility for software providers to link with GP softwares. Moreover the software that is sometimes provided by nursing homes is unsatisfactory for GP purposes and most importantly, does not meet GP accreditation standards. For instance, GPs need to be able to transfer their notes electronically. It is time consuming to duplicate in nursing notes what we write in our medical notes.
Q. How important is it to treat the elderly in their homes or aged care facilities?
I think it is very important to treat patients in their homes or at RACFs where possible and where they are surrounded by support systems. But it is also true that these people have paid taxes all of their lives. So living in an aged care facility should not act as a barrier to them receiving proper healthcare in a hospital. I don’t think we should abandon people because of their age or cognitive impairment.
Q. What are the specific needs of an aged care patient in a residential facility that doctors and others in the community need to understand?
This is where there is more an art to medicine than science. We need to understand that a lot of evidence-based medicine does not necessarily apply to people in extreme old age suffering from multiple comorbidities. Another important factor to consider is continuity of care, where a single GP or a small group of GPs looks after all the patients in an RACF. This way, the GP can provide a holistic and personalised response to the patients’ medical needs.
Q. What is the greatest challenge facing our elderly today in terms of disease and illness?
The most common illness, and also the most challenging to treat, is dementia. Polypharmacy and multiple comorbidities are also widespread. Perhaps the greatest challenge is to receive judicious treatment that is appropriate to their age and condition, which is based on looking at the patient holistically and taking into account the wishes of the patient and the family.
Q. Is Australia prepared to handle its fast-ageing population?
The government is putting in place measures that are going to prove inadequate. I think it is good idea to introduce telehealth into RACFs as well as to up-skill nurses within facilities. However I don’t agree with independent nurse practitioners. There should be a greater team approach with the GP as head. There has to be some chain of command.
For more in-depth coverage on Australia’s ageing population, please refer to the latest edition of Medicus.