For GPs in Australia, an increasing amount of time is spent managing patients with chronic health problems using tools called care plans. There are GP Management Plans, Team Care Arrangements, Health Checks, Mental Health Care Plans, Asthma Management Plans, Diabetes Annual Cycle of Care and others. Most of these involve filling out a lengthy document outlining the patient’s health issues, medications, progress and goals. Often these plans are produced collaboratively between the practice nurse and the doctor. At the end of the process, the patient is offered a copy of the plan and a significant sum of money is paid by Medicare to the doctor. But is this process effective in achieving improved outcomes for people with chronic diseases? Is this process working for Aboriginal people particularly?
I shudder at the thought of how many trees were required to print the number of care plans I’ve produced over the last 4 years. However, I have been able to work in a number of different settings around Australia where this approach to chronic disease management has been used. I have worked in 3 mainstream GP clinics, 5 Aboriginal medical centres and 4 hospitals and I think this range of experience has given me some insight into how the system of care plans works to improve health outcomes. Unfortunately, my experience is that most of the time these documents we produce are not really that helpful for the patients we serve.
My experience of health checks or care plans has been varied. In some clinics, the bulk of the work is done by the organised practice nurse, and my role is to sign off on the document and discuss issues that have come up. Other times, a patient is brought in for a health check and it is up to the doctor to complete the whole document. The vast majority of these checks and plans have been initiated by the doctor or health service, and not the patient. It also seems that most of them are done for patients who already have frequent contact with a health service. Working in Aboriginal health, I’ve found myself often in the frustrating situation of having to do a health check and tick boxes for a patient that I’ve been seeing regularly, and all the questions and discussions that have to be had seem repetitive. Quite often patients are keen to leave and don’t see the point. I offer to print out the document and wonder what percentage end in the bin.
To try and make the process more medically satisfying, I try to ask each person what their own goals for their health are. It’s then a matter of balancing their goals with the medically recommended goals. Which is the most important goal- to get that HbA1c below 7, or to stop feeling tired all the time? Even when I’ve tried hard though to ask patients about their goals and help them set a path to improved health, the whole process feels unsatisfying and I wonder if the patient walks away wondering if the whole thing was worthwhile. I can’t help but feel that is some settings these care plans and health checks are simply revenue raising for the health service to continue.
Despite my cynicism, I would love to know if on a population level the effort of doing health checks and care plans is achieving something. There’s a strong case made for the efficacy of preventative health assessments by NACCHO in the “Evidence base…” document.
So, is the system working well for Australians? Is it working well for Indigenous Australians? How could it be better? Personally, I find it inefficient that as a doctor I’m paid a significant amount of money to produce a document of questionable benefit to the patient I’m seeing, and that this is a requirement to access funding to provide care that is already happening. Perhaps it’s time to move to a capitation model like the UK?
I would love to hear your views in the comments. Have you got ideas about how the system could improve? Are you a doctor who has done care plans or health assessments? Any suggestions about how they can work better, especially for Indigenous people? Have a rant in the comments.