Saturday 28 December 2013

Part 2 of Australian Adventure- Sydney to The Gold Coast

Drove from Sydney to Surfer's Paradise along the Pacific Highway. Distances are in Kms but the speed limit was 90 Km/Hr and in many places there was construction going on to build bypasses  avoiding towns and temporary speed limit of  70km/hr were in place.

Wherever possible we took the designated scenic routes;  so we took our time- the whole point of driving! We had a Holden Commodore- an Aussie built 'large car'. 3.6lt Aussie muscle-very comfortable and great suspension for the roads and a huge boot which easily swallowed our luggage and baby stuff. We were very impressed with the  car- sad to hear its ceasing production soon. A couple of Aussie Motel owners were very impressed that I had chosen to rent one of these.

Must mention the highway- everyone follows the speed limit. 90km/hr means just that. Signs warn 'Speed cameras anywhere, anytime' and Police hand out on the spot penalties and fines. Saw some patrol cars but even on deserted roads everyone stuck to the legal limit. Made for a much more relaxed driving experience. In fact everywhere we went people were much more law abiding. No graffiti, litter, drinking on the beaches or public places etc. Again we were impressed and it was noticeable on a short stay. Nor did it feel oppressive like a police state.

Nambucca Heads on the Pacific highway

View from Motel
A typical Aussie motel- room with separate kitchen and a balcony. Much easier to live in than a typical hotel room especially with Aryan. He always had space to play and run around. In the little Gazebo was a BBQ and the owners were very friendly and helpful- again an Aussie trait if Motel Owners are anything to go by


Aparthotel Q1 Resort, Surfer's Paradise- Very swish!

View from 21st Floor Balcony

At the Beach Surfer's Paradise
Q1 Resort Pool
View from the Observation Deck on the  78th Floor
So, we loved the drive and arriving in Surfer's Paradise and especially the apartment at Q1 Resort was magical. 

The promised lifestyle and weather were all present in abundance and its easy to see why people fall in love with the place. We returned not via the pacific highway but on the inner roads which were better in many ways. After a short stay in Kiama which was highly recommended by my cousin we headed on to Melbourne to visit friends and from there to the 12 Apostles and then sadly back home to blighty!
Part 3- Melbourne

Monday 23 December 2013

Our Australian Adventure- part 1 Getting there!



Packed and ready to go
On the plane- Birmingham -Dubai with Emirates
Dubai from the Air
The A380 beofre boarding. From Dubai to Sydney. 14 long hours!

Sydney Airport. After 24 hrs in the air and almost 36 hours later. Gruelling
First impressions- much smaller than we thought. Comparable to Birmingham Airport. People are much more friendly and there are lots of languages being spoken; most we can't recognise!
Next Blog: Sydney and the Gold Coast




Saturday 21 December 2013

Costs and Outcomes- NHS v/s Medicare

So how exactly does the Australian system compare vis a vis the NHS?

Does giving Drs complete freedom make them irresponsible clinicians? Do costs skyrocket?
What about outcomes- how do they compare?

Exact comparisons are of course well nigh impossible but people have made a stab at comparing health systems- each one invariably comes out with a different outcome but have a look at the link below. It talks about the most efficient health systems. I think the gym analogy ends here for several reasons:
  • The health industry is much more regulated.
  • Though there may be competition most countries will map Drs to demand. In UK the average GP has 1800-2000 patients registered with them. In Australia, the govt earmarks Areas of Need (AON) and District of workforce shortage (DWS) where it tries to match numbers of Drs to demand and actively directs Drs where there is a shortage. So unlike a gym when GP surgeries exist close to each other the number of patients is sufficient for both to exist.
Bloomberg has used what it calls 'Efficient health Care' as a means of judging success- this is based on several parametes including life expectancy and per capita costs. UK is number 14 on the chart. And Australia? No. 7. For a full list see here (Updated 2/12/14 the link has been updated and some rankings/figures are now different)

So clearly a capitation based system cannot be said to be superior in principle. There is some merit in saying that a free market economy model does lead to spiraling costs as in the USA (ranked 46) but this is an Insurance lead model and not a levy on income based model like medicare.

But, is it that important? Even UK is not badly placed and 14 isn't too bad. However, there are some compounding problems which I feel will widen this gap to the detriment of UK. UK has an ageing population and though Australia is aging too it is a)younger to begin with and b)growing older more slowly. The median age (Median age is the age that divides a population into two numerically equal groups - that is, half the people are younger than this age and half are older) of Australia is 37.5 and of the UK 40.5 (For a full list see here)
If that wasn't enough the projected number of people over the age of 65 in 2020 stands at over 19% for UK and just under 16% for Australia. Even in 2050 Australia will have less over 65s than UK (see here).

Remember what I said about 10% of your population using up 90% of resources? Well, the vast majority of those reside in the over 65 age group. So, if a country has a higher burden of over 65s and this is projected to grow; where should said country concentrate its resources? But, just at this crucial juncture the NHS has embarked on a project to save £20 billion by 2020!!

A recent kings Fund report states :From 2012 to 2032 the populations of 65-84 year olds and the over 85s are set to increase by 39 and 106 per cent respectively whereas 0-14 and 15-64 year olds are set to increase by 11 per cent and 7 per cent respectively.
That means the work force will shrink and those requiring increasing support will increase exponentially. Whilst the report states that the elderly still make a net contribution to the economy even after taking the increased health care costs it is clear that health care costs do go up. 

At precisely this time the NHS is faced with low staff morale and reduced staffing levels. The RCN(Royal College of Nursing) has identified 68,880 NHS posts marked for cuts by 2015; of these 24,836 have already gone, of which 4,837 are nurses, midwives or health visitors, and 4,042 are healthcare assistants. 
Five Psychiartry consultants from my local hospital have upped sticks and gone to Canada- this at a time when a dementia epidemic is predicted! And the number of Drs requesting Certificates of good Standing from the GMC (a surrogate marker for Drs intending to migrate) is going up.

As a clinician I can't help but feel alarmed at these changes. And as a potential patient? Is this why we are going to work longer, pay more in NHS contributions, taxes etc? The focus seems to be on short term gains and a longer strategic vision seems to be missing. 

This I must point out is not an inherent fault of the Capitation based system. It does, in my view lead to the wide variation in primary care that is evident in UK and some people think the NHS reforms were motivated by a desire to dismantle this. 

If true, it seems an unnecessarily convoluted way of doing things and may have potentially disastrous and unintended consequences

I started by ending an analogy. I'll end by starting another. The NHS reforms centered around making Drs commissioners and putting them in charge of budgets instead of managers. The presumption I guess was that as clinicians they would make sound clinical decisions and commission more cost effective services based on their local population needs. 

But is there any evidence that this is the case? You could argue that its too soon to say. But the effects of this reorganisation itself; seem to me atleast, to be having the opposite effect.

So the analogy? If we assume the NHS was the military and apply the same principle- ministers, managers, manufracturers are messing up the budget so lets give control to the soldiers. Therefore like CCGs commanders from the 3 services lead and control expenses, acquisitions, deployment etc. Makes sense? 
Now in this scenario, can you imagine a Commander from any service going up to Parliament and willingly accepting cuts? Or actually making bigger savings than targeted (for 2011/12 the NHS delivered a surplus of over £2billion!) and then accepting even bigger cuts year on year? This is exactly what Drs as commissioners are doing (my personal opinion again). So they may make cuts in troop sizes (NHS is loosing frontline staff so an apt comparison), reduce services altogether like close bases (akin to closing hospitals or A&E departments). Is that what  the armed forces do? or the police chiefs??

No- they have budget cuts imposed on them. They protest loudly and spell out the dangers of those cuts that they foresee. Then they try and deliver what they can. They are candid with the public- the police chiefs come out and say openly that due to cuts there will be less bobbies on the street for example.

But, when it comes to the NHS,  politicians promise a world class health system to the public. Yet, they allocate a budget which makes it impossible to deliver this, leave alone investing for the future. And the Commissioner Drs? Do they protest like the Police chiefs or Army generals? No! they act like they believe the cuts are justified themselves and make compromises to deliver what they have been asked to. This erodes patient confidence in their GP. This to my mind is the biggest debacle of the whole situation. If the Govt is unwilling or indeed simply unable to spend what it takes to deliver a world class health system then it should be candid about this with the public. 

We as Drs should demand more funding and expenditure per capita if that is what is required (and evidence I have presented above would indicate that it is). We are always told that there isn't an infinite pot of money- in fact there is! The spend on NHS as a percentage of GDP is not only tiny but shrinking. 

The govt will shout form the rooftops that spending per capita on NHS is increasing year on year. However, as a percentage of GDP it is falling!

Don't believe me? Look here at the figures  for yourselves. 

I ask again- with an ageing and growing population should the Govt spend more or less on the NHS as a percentage of GDP? And as Drs what is your duty to your patients. Think long and hard before you answer that if you're a Dr.

Next blog- I visit Australia!


Monday 16 December 2013

The Australian model- fee for service

So what is the Australian model? This is called a fee for service (FFS) system. 
Keeping the gym analogy going- if the UK capitation system is like a monthly direct debit, the FFS model is like paying a fee each time you use the gym but with no monthly payments. Obviously, you pay according to the services you use. 

Many advantages are immediately apparent: it costs nothing to those who don't use the gym. Light users don't subsidise heavy users. If demand goes up, the gym owners simply invest in more facilities, equipment,staff etc. The gym owners have no incentive to try and squeeze profits by providing inferior services or trying to curtail use of their facilities. In fact, they are more than happy to oblige their customers as they are competing with other gyms 

So what about the disadvantages? Firstly, continuity of care is a casualty. People are free to go wherever they like and are not registered with any one practice or doctor (no monthly direct debit). 
Secondly, since people pay a fee to get in, the assumption is they will want something for it so mere reassurance or an offer to review later doesn't work as it does in a capitation based system. Drs feel obliged to investigate or prescribe in such a system. Also from a business point of view it is inherently more risky- you invest in a new service or staff and patients leave to join a new practice across the road. 
Also there is a risk of spiralling costs- there is no cap. Patients demand more and more and business just keeps expanding to fill the demand putting the whole economy at risk. 

But, patients are not gym goers and most people like to see one Dr and value continuity of care. So what is the evidence? Is there evidence that Australia or Canada spend huge amounts on health care? And what about outcomes. Who fares better?

In my next post I will evaluate the evidence to see if any of the assertions are indeed true. 

Tuesday 3 December 2013

Australia - An NHS GP abroad

I am a GP in UK and have been practicing for about 5 years now.

In the UK we have a capitation based system for GPs. This was a hard concept  for me to grasp when I first started. A senior colleague and friend explained it to me with this analogy:
It's like a gym membership. People sign up and you get paid a fixed sum for everyone who signs up. You then actually make a profit from the people who sign up but don't use your facilities. 

People who actually use the gym cost the gym owners money. A gym can try and extract some revenue from them by offering them extra services like cafeterias, saunas, physiotherapy,massages etc.

GP surgeries are exactly the same. They get paid a certain amount for providing 'core services' and then they can bid for certain 'extras' called enhanced services or offer other services from their premises like insurance medicals or travel vaccines. 

But the bulk of the income comes from the 'core contract'. Traditionally, GP profit again comes from patients who are registered with the practice but never use the service- the general wisdom is that 10% of your patients will use about 90% of your resources. 

Now, it becomes obvious that a gym in order to maximise profits has to do the minimum possible for the people who do turn up to the gym and yet keep them happy. 
Obviously, if more and more of the members who paid their dues started turning up or the number of people who do turn up started demanding more services then the profit margin of the gym would be affected. In order to resolve this gyms can put up their prices. 
But, the GP contract is centrally negotiated and GPs cannot charge more capitation fee. With an ageing population and increasing demands from the worried well it is obvious that the number of people using the service is increasing. But, If the capitation fee doesn't increase in line with this increasing demand then GP surgeries are bound to suffer. 

This has been going on in the UK for the past several years and puts Drs in a very awkward position and often affects the whole health economy. This is also responsible for the wide variation seen across GP surgeries in the UK. Consider a simple scenario:  a GP surgery sees a big increase in number of patients with diabetes registered with them. A logical response for them would be to hire a diabetic nurse specialist to support these patients-initiate insulin, carry out regular checks, educate them regarding diet, exercise etc. In this way they could keep referrals to the hospital or other services to a minimum and cost the exchequer less money. 
As a clinician this is obvious. But as a businessman? (Think what a gym owner would do in a similar situation) A practice will not be compensated for hiring this staff member or for upskilling their existing staff. 

On the other hand, if the practice chooses to refer every patient requiring insulin to the hospital it will cost them nothing! Thus, they can affectively have a nurse with lesser training and on a lower pay scale or even an Health Care Assistant instead of a nurse and have a higher profit than compared to another practice who chooses to have the requisite skills in house. From a business point of view the approach of the first practice makes sense and that is what a gym owner would do. But, does that make sense in a health context? 

More importantly, as a GP principal having to make these decisions where monetary considerations conflict with your clinical judgement, training and desire and need to serve your patients how does it affect your morale? How does it impact on that holy of holies- The Doctor/patient relationship?

This blog is an account of my journey from here on.

I have been grappling with these issues for some time now. When the government announced that they were giving powers to the GPs to commission services instead of the PCTs I was naive enough to believe this would change things. Surely, GPs would look at the needs of their populations and ensure appropriate services were available to all patients. But, this too has turned out to be a mockery of the original proposal- GPs are in charge of commissioning services from hospitals but have no say in how GP surgeries are run. Since 90% of NHS consultations occur in GP surgeries it is obvious that this change cannot and will not change grass root GP practice and the conflicts I alluded to that GPs particularly principals face will continue.

I am not alone in being disillusioned thus. Apparently, there is a veritable stampede of NHS Drs emigrating to places like Australia, Canada and increasingly the Middle East. 
Some time ago, I decided to explore my options and for various reasons settled on Australia as a potential destination for me and my family. 

First I did try and understand their health and GP system. The Australian and indeed the Canadian system is a fee for service model. More about this in my next post