I was reminded the other day of some wisdom from JFK when he was trying to motivate the USA to embrace change. “There are costs and risks to a program of action, but they are far less than the long term risks and costs of comfortable inaction”. Healthcare is a changeable landscape which has increased average life expectancy by over 30 years since 1900. When such continuous clinical development is coupled with the periodic meddling of the bureaucracy and other funders, one can feel change fatigued. Too often, we become change hardened. That is why the opportunity to travel for a week with a group of Aussies to two countries has opened our eyes to the world beyond our back door. It is a different outlook with dangers and possibilities which we must deliberately sift and disseminate.
Core to the changes in healthcare occurring on the north American continent is the increasing diversity of the primary healthcare team. Nurses, allied health and even the social sector are lined up beside doctors to deliver a comprehensive solution which is accessible and focused on long-term patient healthcare gains. In previous blogs I have talked about how this patient centredness is changing the funding and approach to care.
This time I would like to reflect a little more on the dynamics of the teams created through a patient centred model of care. The most noticeable change is the dramatic change in the ratio of doctors to nurses. Nurse numbers end up outweighing physicians. This is a radical departure from primary care in Australia where unlike hospitals and community care, doctors outnumber nurses by a significant multiple. Even more interesting, different sorts of nurses are found, each working to the full extent of their scope of practice. Everywhere I have been in New Zealand, Canada and the USA, Nurse Practitioners were present. In addition, Registered Nurses were often broken into two strata with one group more empowered to case manage, educate, review scripts and undertake procedures. The other group were used to support the lower level clinical work involved in triage, referrals, recalling patients and my latest favourite nursing task; phoning every patient at risk of hospitalisation or recently discharged from hospital. Enrolled level nurses were also present undertaking a multitude of patient work-ups and clinician support.
The sharing of data in all three of these countries regarding hospital admissions and frequent flyers far exceeds anything planned in Australia. Yet it is driving results! When you hear a hospital CEO jokingly bemoaning the difficult decision he faced in laying off staff because primary care was reducing his ED visits and bed days, you know something significant is afoot.
Today we were further challenged about who is involved in care. A truly patient centred system engages the patient in decision making in new ways. Too often, the decision for treatment is largely determined the moment a GP writes a referral, especially if it is for surgery. The only remaining question is when such surgery will occur. With shared decision making, Canada is leading the way in so fundamentally changing the process of organising care that significant surgical savings are being made because patients are choosing different care options. Core to many of these approaches is general practice physician and nursing involvement in educating patients and supporting them to identify their values and goals when faced with a care “fork in the road”. Better engagement at this point in the patient journey is revealing how many other clinical options are available which often generate far superior satisfaction and much lower cost. We even heard of surgeons moaning about the demise of their lists. I imagine their CEOs must be happy though, in that case study it produced a 50% reduction in surgical activity!
To institute such shared decision making tools are required. Coaching in how to engage and support patients also needs to be delivered and then there is the additional time involved in working with patients to reach a decision. However, when you hear that some jurisdictions have found the process so value creating that they have now started funding this activity, or even gone one step further to incentivise not doing surgery, you know you are not looking at window dressing.
It has been especially fun walking on the wild side with other members of the Canada and US Knowledge Exchange Tour from the Australian Association of Practice Managers. I am seeing the world in a new light. I hope you are too and like JFK exhorted us, wondering whether comfortable inaction is tenable any longer in the Australian landscape.
Tracey Johnson, General Manager, Inala Primary Care