The rising tide of chronic disease
Caring for patients with chronic and complex conditions is one of the greatest challenges facing general practice and other primary care providers. The latest National Health Survey found that 11.4 million Australians, almost 50 per cent, now have a chronic disease.
It has been suggested that digital technologies could assist by decreasing the administrative burden of care delivery, improving quality of care, increasing practice efficiencies and better supporting patient self-management. All the while lowering cost. This panel discussed how technology can be used to support the treatment of chronic conditions. What role does it play in improving continuity of care? And how can we use it to empower patients to take control of their own health management?
- Professor Rosemary Calder, Professor of Health Policy, Mitchell Institute Victoria University
- Emma Lonsdale, Executive Officer, Australian Chronic Disease Prevention Alliance
- Jane Calligeros, Registered Nurse and CEO, CDM Plus
- Natalie Raffoul, Cardiovascular Risk Reduction Manager, Heart Foundation
- Harry Iles-Mann, Health Consumer Co-design and Engagement Consultant
The latest figures show that almost one in two Australians are living with a chronic condition in Australia. And when you factor in family, friends and carers, there’s very few Australians who are not affected by chronic disease.
“It’s an enormous burden and has a huge impact on Australians,” says Emma Lonsdale, Executive Officer of the Australian Chronic Disease Prevention Alliance.
Worryingly, the number of cases of chronic disease is on the rise. Emma points to two main reasons for this increase: our ageing population means people are living longer with chronic conditions, and an increase in modifiable risk factors like obesity.
By changing these risk factors, Emma reasoned, we could significantly reduce the impact of chronic disease. “If everyone in Australia was a healthy weight, we could reduce diabetes burden by over 50% and chronic kidney disease burden by 38%.”
Early detection is one of the most important tools in the fight against chronic disease, but there are significant barriers – most notably a system that is not set up to support prevention, Emma points out.
“Our MBS items don’t always align with the guideline recommendations. For example, chronic kidney disease is one of those conditions where you can lose 90% of kidney function before you show symptoms. GPs don’t always have the resources to be able to detect those conditions early enough.”
A national framework for prevention
Having a focused and systematic way of dealing with prevention at a national scale is something that the panel agreed should be a top priority in Australia.
However, this model of prevention needs to be properly resourced according to Professor Rosemary Calder, Professor of Health Policy at the Mitchell Institute Victoria University.
“GPs are set up to respond to illness, not to prevent illness, or to address risk factors for preventable disease. We need to help shift the model.” She points out that the burden of change can’t rest on the shoulders of GPs alone.
“We’re expecting general practitioners, who are largely small businesses, to also manage a business process that changes the way in which they function and practice. All this requires a policy framework that helps drive prevention and early intervention into the system. We can’t expect GPs to be the ones to make it happen.”
Balancing self-management and intervention
Health Consumer Co-design and Engagement Consultant, Harry Iles-Mann agrees that GPs shoulder a significant burden and should be recognised for this.
“GPs are considered the gatekeepers to the health system and that’s an enormous weight to carry. Unfortunately, the public, the government, and the people that resource general practice and primary care, don’t afford it the same gravitas of resourcing as the expectation that they’re attaching to it.”
As a patient who has lived with multiple chronic issues for more than two decades, Harry urged patients to take a more active role in managing their conditions.
“One of the most powerful mechanisms that I’ve found I can use in managing my chronic health issues is what I do on my end.”
Harry has crunched the numbers and found that of the 8760 hours in every year, 99% of that is spent self-managing his condition.
“Less than 1% of my time is spent with a specialist, a general practitioner, an allied health professional, or in an environment that you would consider traditionally hospital or health-based.”
He believes one of the unfortunate perceptions amongst the public is that it is an ‘all or nothing’ approach when it comes to managing chronic conditions.
“Patients feel either the solution is purely medical and comes from a point of professional medical authority, or they don’t want any involvement and they resign themselves to changing nothing about their lifestyle. The sweet spot is recognizing that there are unfortunately factors that you can’t control and accepting those.
Harry is pushing for a renewed approach to finding a better balance in the way we administer health care for chronic conditions.
“I think that general practice in combination with home care and self-management, is going to play a really key role in that in the future.”
Wearables helpful, but not without GP input
Natalie Raffoul, Cardiovascular Risk Reduction Manager at the Heart Foundation, says building awareness around prevention is an ongoing challenge.
“Most people are not even thinking about preventing their chronic disease, they’re just not engaged with their health until something happens. And so one of our biggest challenges is to get them to even think about how diabetes, cardiovascular disease, and chronic kidney disease could be relevant to them.”
She suggests wearable technology such as heart monitors, fitness trackers and health apps could be one solution, helping to bring greater awareness, improve health literacy and engage people in their health.
“We’ve seen an exponential increase in fitness, wellness and health-related apps. But I think the jury is still out as to whether or not these wearables can effectively screen, particularly compared to the tools we have available at our fingertips in a medical setting.”
“There’s no doubt that the advent of these wearables means there’s more information. The challenge will be how we use that information,” she warns.
Emma Lonsdale agrees that wearables are a step in the right direction when it comes to empowering patients, but it’s important to use them in conjunction with health professionals.
“They might pay a bit more attention to their heart rate and it might be an incentive to go to their GP. But there are lots of health apps out there and they’re not all regulated, so it’s really important that people feel comfortable to work with their GP using these apps,” she says.
Technology can help ease the burden, but nail the basics first
Jane Calligeros Registered Nurse and CEO of CDM Plus says technology can help GPs manage the influx of chronic conditions, but many are turned off by the complexity of change.
“The barriers that we see all the time in clinics that we work with are issues around the software they’re using. There’s often no set systems or processes for chronic disease management.”
“There’s so many challenges that we face to get the chronic disease management even up and running. And the problem is, it’s a long time solution that we’re looking for. But a lot of clinics get frustrated and it just falls over and they give up. It’s just too hard,” she notes.
Jane advises practices to get “back to basics” when it comes to using technology to manage chronic conditions. She says ensuring people know how to use the underlying software first is key.
“I find a lot of the issues when we’re doing training is if you go to add a new system or process on top of what you assume they’re already doing, it’s just setting them up to fail because they haven’t got the basics right.”
“The best place to start is to recognize what you do well in your clinic and to recognize where you could improve in a couple of the areas. Changing processes and adoption of new systems takes time, don’t rush it,” she concludes.
The latest national health survey found that 11.4 million Australians almost 50% now have a chronic disease. Caring for patients with chronic and complex conditions is one of the greatest challenges facing general practice and other primary care providers.
Dr Charlotte Middleton (00:00:16):
It’s been suggested that digital technologies could assist by decreasing the administrative burden of care delivery, improving quality of care, and increasing practice efficiencies, and better supporting patient self-management, all the while lowering cost.
Dr Charlotte Middleton (00:00:32):
How is technology supporting the treatment of chronic conditions? What role does it play in improving continuity of care? And how can we use it to empower patients to take control of their own health management? Joining us today is Rosemary Calder Professor of Health Policy at the Mitchell Institute Victoria University. Hi, Rosemary.
Professor Rosemary Calder (00:00:55):
Hi. Good to meet you.
Dr Charlotte Middleton (00:00:57):
Emma Lonsdale, Executive Officer of the Australian Chronic Disease Prevention Alliance.
Emma Lonsdale (00:01:01):
Hi, Charlotte. Thanks for having me.
Dr Charlotte Middleton (00:01:04):
Jane Calligeros, registered nurse for 20 years and CEO of CDM Plus.
Jane Calligeros (00:01:09):
Hi, Charlotte. Thanks for having me.
Dr Charlotte Middleton (00:01:12):
Natalie Raffoul. Cardiovascular Risk Reduction Manager at the Heart Foundation.
Natalie Raffoul (00:01:17):
Thanks for having me.
Dr Charlotte Middleton (00:01:18):
And Harry Iles-Mann Health Consumer Co-design and Engagement Consultant, and a patient who has lived with more than two decades of multiple chronic issues.
Harry Iles-Mann (00:01:27):
Thanks for having me.
Dr Charlotte Middleton (00:01:28):
Pleasure. Well, everyone, thanks so much for joining me here today for what I’m hopeful will be really interesting discussion around chronic disease in Australia. So I’m going to jump straight in. Look, as we’ve alluded to chronic health disease is obviously increasing exponentially.
Dr Charlotte Middleton (00:01:45):
I think in 2014, it was around 7 million. Now the latest figures are that we’ve got 11 million Australians living with chronic disease in Australia. Emma, I might start with you if that’s okay. What do you see are some of the challenges that we’re facing in terms of chronic disease management at a industry level and why do you think this number is increasing?
Emma Lonsdale (00:02:06):
So first, I think we need to really recognize the disease burden. So you said 11 million people. That’s one in two Australians who are living with heart disease, stroke, diabetes, kidney disease, and cancers. And plus, as well as these people, you’ve got their family, friends carers. So it’s a really huge, it’s enormous burden and impact on people in Australia.
Emma Lonsdale (00:02:27):
So why is this number increasing? Well, we’ve got a growing and aging population. So there’s more people living longer with these conditions and with disability. But aside from that, chronic diseases are closely linked to modifiable risk factors. So we’ve got more people who are living with overweight and obesity in Australia.
Emma Lonsdale (00:02:46):
In fact, two in three Australian adults have overweight or obesity. One in four children are overweight or obese, and they have more risk of growing up with overweight and obesity as well. So you have these risk factors that are contributing to people’s risk of disease, long term risk, and also risk of earlier death for some people as well.
Emma Lonsdale (00:03:09):
I just wanted to mention as well that if we could change these risk factors, we could really reduce the impact of disease. So for overweight and obesity, for example, if everyone in Australia was a healthy weight, we could reduce diabetes burden by over 50%. Chronic kidney disease burden by 38%.
Dr Charlotte Middleton (00:03:26):
They’re crazy numbers but yeah, yeah.
Emma Lonsdale (00:03:28):
So it’s really important that we look at how to prevent these diseases by changing our environments as well, not just managing the conditions we’ve got.
Dr Charlotte Middleton (00:03:35):
Some really great points there. Rosemary, in your position, what have you been seeing?
Professor Rosemary Calder (00:03:42):
We’ve been looking at the patterns behind the chronic disease epidemic that’s affecting the world, not just Australia. It’s a worldwide phenomenon that’s related to the changes of the last 50 to 70 years. We’re now living sedentary lifestyles. We’re all sitting here talking to each other, whereas our forebearers would have been outside working in either physical labor on agricultural properties and the like.
Professor Rosemary Calder (00:04:09):
And our bodies haven’t adapted as fast as our lifestyle has. We have a food chain where very few of us now would source and prepare our own food. It’s very much pre-prepared for us. So it’s absolutely a fact that it is our environment, that it’s our world environment. And we have to change it by working with both individuals and health professionals and others, people who influence urban planning, people who influence the way in which we engage people in physical activity, enabling us to walk, ride, or run to work rather than by car.
Professor Rosemary Calder (00:04:47):
We need to change the environment in which we all live and work. But we also need to help people understand that it is about the world in which we live and how we engage with that world that is behind our chronic disease problems.
Dr Charlotte Middleton (00:05:00):
I couldn’t agree more. Anyone else would like to add to that?
Harry Iles-Mann (00:05:03):
If I could just jump in to say from the patient side of things as well, that to me has been one of the most powerful mechanisms that I’ve found I can use or is at my disposal in managing chronic health issues is what I do on my end. There is, in most situations, a finite amount that can be done in what you would consider is traditionally a medical setting.
Harry Iles-Mann (00:05:28):
And one of the examples that I like to use in talking about my own care is that out of 8760 hours, in every year, 99 plus percent of that having broken down the numbers, is me managing my own health. Fewer than 1% of the time that I spend of the hours of every year is with a specialist, a general practitioner, an allied health professional, or in an environment that you would consider is traditionally hospital or health-based.
Harry Iles-Mann (00:05:59):
So my capacity to affect the variables and the environment around me is one of the most powerful things that I have at my disposal to actually take some control over my health. And I think, unfortunately, one of the perceptions that is out there amongst the public is that it is a all or nothing approach.
Harry Iles-Mann (00:06:16):
It’s either that the solution is purely medical and clinical and comes from a point of professional medical authority or they don’t want any involvement and they resign themselves on the other end to changing nothing about their lifestyle, where the sweet spot in the middle is recognizing that there are unfortunately factors that you can’t control and being comfortable with those and accepting those.
Harry Iles-Mann (00:06:41):
But then also recognizing that well, hey, there’s five, six, seven things that I can do about my health and my lifestyle and my environment that will actually make an impact on my quality of life, how I manage my care, and then also, how it affects the lives of the people around me or the people that are caring for me.
Harry Iles-Mann (00:06:59):
So I think it’s important that we take a renewed approach to finding a better balance in the way we administer health care. And I think that general practice in combination with home care and self-management is going to play a really key role in that in the future.
Dr Charlotte Middleton (00:07:16):
That’s a pretty powerful statistic, the numbers. When you-
Harry Iles-Mann (00:07:19):
I can’t say for everyone, but when it comes to me, I probably have more engagement with the health system than most.
Dr Charlotte Middleton (00:07:26):
Harry Iles-Mann (00:07:26):
So it might not be the most representative. But it’s still a pretty powerful number when you think about it.
Dr Charlotte Middleton (00:07:33):
And that’s actually it’s a really good segue. Jane, I was going to ask, given your experience in general practice and what you do now is we know that there’s a lot of barriers in general practice to optimal chronic care management, Medicare, confusion around the billing, the administrative burdens, lack of connectivity between care teams, particularly.
Dr Charlotte Middleton (00:07:57):
Is there some silver bullet? How can we improve things? And that’s asked quite facetiously because I know there isn’t. What can we do at a practice level?
Jane Calligeros (00:08:08):
I think the best place to start is to recognize what you do well in your clinic and to recognize where you could improve in a couple of the areas. The barriers that we see all the time in clinics that we work with are issues around the software they’re using.
Jane Calligeros (00:08:26):
So they haven’t had training, how to use it, things like that. There’s no set systems or processes of how they’re actually doing the chronic disease management. So if one nurse is doing it one way, there’s 10 different templates for one type of health assessment or care plan. So it’s very disjointed at a lot of clinics.
Jane Calligeros (00:08:47):
Part-time workforce, that there’s just so many issues facing the clinics. There’s high staff turnovers. Patient engagement, so a lot of clinics struggle to get the patients back into the clinic. And I agree with Harry, in that I think the future of the primary care is a combination of the GP like home care and that self-management because the number of patients outweighs the number of resources that we have in primary health care.
Jane Calligeros (00:09:20):
There’s just no possible way that we can care for that many people with chronic conditions at a management level and yet target the patients that need those early detection and prevention activities as well. So most practices would have an average population of four or 5000 patients. So half of those have a chronic condition and you would assume that they would at least do a care plan and a review with those patients in a 12-month period.
Jane Calligeros (00:09:49):
But what ends up happening is that’s the 5000 appointments, which is 20K plan and review appointments a day in a clinic, and it’s rare that that actually happens. So they’re not even targeting half of those appointments, which makes it difficult then to turn around and actually provide preventative like health assessments and other activities in the clinic when we can’t manage those with the chronic conditions to start with, which just makes a bigger problem.
Dr Charlotte Middleton (00:10:21):
Harry, obviously, you’ve alluded to that how important it is that patients are involved. What more can we be doing do you think?Two of the things that have always stuck out for me, is the way that we engage with our emergency departments is that for the most part, the majority of us use it as if it was a general practice, which it’s not something that’s done maliciously by people.
Harry Iles-Mann (00:12:44):
But it’s because of the lack of an understanding of what an emergency department is for. 70% of the caseload burden in emergency departments are triage categories that would be more equitably and efficiently serviced through health clinics and general practice.
Harry Iles-Mann (00:13:03):
So emergency departments themselves are having to deal with all of these extra people, which is a huge draining resources when it would cost you a fraction if you went well, for this issue, I don’t need to go to my local emergency room. I can go to my GP instead.
Harry Iles-Mann (00:13:44):
So if we were able to implement change that just affected 1% improvement, we would fund headspace nearly twice over annually, which is a huge change. And we know that people with chronic health issues are eight to 10 times more likely to develop an associated mental health issue as well.
Harry Iles-Mann (00:14:04):
So if we can try and combat some of these really significant issues outside of the primary care space and the general practice space, there will be immediate and an enormous flow-on benefits that feed back in and free up a huge amount of resourcing so that we can provide higher quality, more accessible, and more personally tailored care to patients with complex needs.
Harry Iles-Mann (00:14:33):
So I think it’s unfortunately, there’s no clean answer to it. But it is a case of all of these departments, organizations, individuals, practitioners, advocates, we need to come together on this and we need to find a common ground and a common direction and push for that.
Dr Charlotte Middleton (00:14:50):
It’s very much I think about educating people and empowering our patients. My parents didn’t even know that chronic care plans existed because their GP hadn’t brought it up. And it was when my dad with a chronic injury was talking about seeing a physiotherapy. I said, “Why are you seeing them?” And he was eligible in other ways. I said, “Why aren’t you seeing him under a care plan?” He said, “Oh, the doctor never told me I could have a care plan though.” So it’s about letting patients to know to ask for them.
Harry Iles-Mann (00:15:18):
And I think back to my experience as a kid as well, for nearly seven years, we didn’t know that my medication was on the PBS. So we paid full price for my medication for seven years before we realized that it was subsidized in costs and should be costing as $6.10 per medication.
Harry Iles-Mann (00:16:22):
That not being brought up seems like such a common-sense failing in that process that would have dramatically affected the expenses of a patient and their family and carers. So I think it’s also about making information available at the right time, but also making information available that’s meaningful to patients.
Harry Iles-Mann (00:16:45):
One of the biggest issues that we have is that we develop a lot of these health initiatives behind closed doors with very little patient consultation. So all of a sudden, one day we get this public announcement, hey, we’ve just gone and built this thing for you. Here it is, be grateful for it.
Harry Iles-Mann (00:17:01):
the level of expectation throughout the process and the level of engagement and consultation and co-design with people with lived experience just hasn’t been involved in that decision making-process, which is a shame because there’s so many initiatives over the last decade that have held significant merit that have failed for no other reason than they were presented and people just didn’t want them because they didn’t ask for them. Which I think that’s not a good reason for not having those things not out there in the public helping us.
Dr Charlotte Middleton (00:17:59):
Yeah, absolutely. Absolutely. But look, we’ve mentioned prevention and can we slow chronic disease prevalence, and Natalie, I might turn to you with your organization. And should our focus be solely on patients effectively managing their conditions or should we look at ways of preventing?
Dr Charlotte Middleton (00:18:21):
And I know your organization plays a big role in the CVD prevention space. We talK about absolute CVD risk assessment. Could you elaborate on that a little bit?
Natalie Raffoul (00:18:32):
Yes. So look I think it’s timely to have this discussion because, by the sounds of it, we all agree that our resource capacity is just never going to be enough for the burden of chronic disease. I think Harry, you’ve touched on the fact that engaging consumers and really bringing them along as partners to the solution is critical. And I just want to reiterate that I completely agree with that.
Natalie Raffoul (00:18:57):
But another element to this I think is that we need to start redirecting our resourcing and our priority to preventing the conditions before they develop. And there’s no silver bullet in this area either. But what we do know is that there are some really clear modifiable risk factors as Emma alluded to that contribute to the burden of these chronic conditions.
Natalie Raffoul (00:19:22):
And if you take CVD or cardiovascular disease as the example, we know that the majority, 86% of the burden of cardiovascular disease relates to premature death. So these aren’t people necessarily living years and years and years with disability. They’re dying before they should.
Natalie Raffoul (00:19:39):
And so this, to me is a very compelling statistic to say we need to really buckle down and focus on prevention. We also know that something like two and a half million Australians are at high risk of having a heart attack or stroke in the next five years. Over half of these people have never had an event.
Natalie Raffoul (00:19:56):
So they’re sitting there possibly not even knowing they’re at high risk. And we’re almost waiting for them to develop that condition before we roll out these additional services. And I know that’s not always the case and there are certainly fantastic prevention initiatives that are out in primary care at the moment.
Natalie Raffoul (00:20:13):
But my argument is that there’s not enough of it. We need to redirect resourcing. To your point, Jane, you’re busy trying to deal in primary care with the acute admission conditions and inquiries that come in. But really having a focused and systematic way of dealing with prevention at a national scale is something that I think we can all really agree is a priority or should be anyway.
Dr Charlotte Middleton (00:20:41):
I couldn’t agree more. But do we feel that we’re being supported in that endeavor would be my question? Because certainly, as a GP, I feel that I’m not given adequate resources to allow myself often just even the time to go through the prevention strategies with my patients, as much as I try to. But so that’s I think we’ve got to have that support from government levels down on that.
Emma Lonsdale (00:21:09):
I think we see that MBS items don’t always align with what the guideline recommendations are. So, for example, chronic kidney disease, it’s one of those conditions where you can lose 90% of kidney function before you show symptoms. And at the moment, we expect there’s about one and a half million Australians living with undiagnosed kidney disease.
Emma Lonsdale (00:21:28):
But there aren’t sufficient MBS items to really support that detection in general practice all the time. So general practitioners have to be opportunistic but don’t always have the resources to be able to do that and to detect those conditions early.
Dr Charlotte Middleton (00:21:45):
Jane, your view on that?
Jane Calligeros (00:21:48):
Definitely. Part of what I was so frustrated with the health system that I actually started the company five years ago to try and fix that side of it in general practice. So I try to encourage as many prevention and early detection activities in any CDM activity that we do.
Jane Calligeros (00:22:10):
So whether it’s a care plan review or health assessment or any opportunity with a patient, it’s all about identifying like those risks that you’re talking about Emma like CKD, whatever it is, cardiovascular risk. Doing all of those activities as they appear instead of trying to do a whole separate thing. It’s a way of trying to work it into our everyday activities that we’re already doing with patients.
Dr Charlotte Middleton (00:22:36):
Rosemary, do you have anything to add there?
Professor Rosemary Calder (00:22:39):
I have a lot, actually.
Dr Charlotte Middleton (00:22:40):
Go for it.
Professor Rosemary Calder (00:22:40):
I mentioned it to add enormously to this because I think it is a really important discussion. We’ve just enumerated what general practice is faced with. It’s a tsunami of demand and we expect general practice to be all things to all people and it cannot be. We need to resource it well and the MBS items are only one aspect of that.
Professor Rosemary Calder (00:23:08):
We need to ensure that we’ve got team members working to their full scopes of practice within a primary care setting with full capacity of allied health and we need to have the capacity to identify people at risk. And it should be almost a triage arrangement so that if people come into our practice that it doesn’t require the skills and expertise of a general practitioner to identify the risks that should be done as part of an intake process for both new patients and returning patients.
Professor Rosemary Calder (00:23:47):
That has to be resourced. We’ve been working for some time now on self-care for better health and COVID. The one silver lining perhaps is that the entire nation and half the world has learned that prevention matters. Prevention makes a serious difference to health. So we do have to resource prevention.
Professor Rosemary Calder (00:24:09):
And we have to understand that the way general practice is set up right now. It’s set up to respond to illness, not to prevent illness, not to prevent risk factors, or to address risk factors for preventable disease. So we need to help shift the model. And that means we’re expecting general practitioners, who are largely small businesses to also manage a business process, a design process that changes the way in which they function and practice.
Professor Rosemary Calder (00:24:41):
All this requires a policy framework that helps drive prevention and early intervention into the system and not expect GPs to be the guys and girls who have to make it happen. I think that’s the nub of the issue. It is a policy challenge. It should have been a 20th Century challenge. We’ve left it very late.
Professor Rosemary Calder (00:25:04):
We do have a commitment now to a National Preventive Health Strategy from the Commonwealth, as well as a National Primary Care Reform Strategy, they have to come together and enable capacity to develop that is 21st Century capacity, not 19th Century capacity, which is what we’re working with.
Jane Calligeros (00:25:24):
So many moving parts.
Dr Charlotte Middleton (00:25:27):
But I feel like we all have an opinion on how this needs to work and how this needs to move forward. We just need to get everyone in the same room or maybe just us, maybe just us.
Professor Rosemary Calder (00:25:42):
It’s really difficult and that Harry said very eloquently. And that is the expectation that individuals ought to be empowered to also work themselves to improve their own health. We know that health literacy if I wanted a better term, that means more things to more people, is very much a socio-economically determined knowledge base.
Professor Rosemary Calder (00:26:08):
Those who have opportunities also have opportunities to understand their own health better and to use the now pervasive Google information to the best of their ability. But we have a wide divide in our country, as does most of the world between those who have that capacity and those who have barriers to their capacity.
Professor Rosemary Calder (00:26:29):
So we’ve been looking at self-care and how to enhance the ability of individuals to work with their health practitioners, as Harry said, for the point 1% of the time they see them, and to be better enabled to manage their chronic condition or prevent a preventable chronic condition for the rest of time. That needs a serious commitment to working with the population, working with communities to particularly working with communities of disadvantage.
Professor Rosemary Calder (00:27:01):
And in my view, if you could only do one thing to try and reduce premature deaths, to try and improve the capacity of general practice to work proactively with a at-risk population, it would be focused on communities of socio-economic disadvantage, specifically, tailor primary care models to those communities, work with general practices in those communities to engage and reach out to the at-risk population do what Jane said about the number of health care plans you can do in a day or a week or a month or a year. Let’s look at how better to do that in a high-risk population. If we threw everything at it for five years, we’d make a big difference.
Harry Iles-Mann (00:27:49):
I think to add to that as well, there’s a conversation about I think very rightly is issues of resource consolidation, especially when it comes to Medicare. To use mental health as a really good example. If we know on an evidence basis that it takes 12 sessions to effectively treat a mental health issue. Why is the cap 10?
Harry Iles-Mann (00:28:15):
That fundamentally is at odds with achieving a positive outcome for the patient. It means that if it takes 12 and we only do 10, we’ve wasted 10 sessions worth of money because the patient’s no better off and we’ve just spent all this money as part of our MBS structure.
Harry Iles-Mann (00:28:36):
So we need to rethink and build again from the ground up and re-evaluate our health system and I think and the point has been made I think very aptly is that our health system as it stands is very much a reactionary entity. It has historically been built in response to events and developments. There’s no or there are very few components of our health system more broadly that are for purpose constructs.
Harry Iles-Mann (00:29:02):
And because of that, its capacity to respond to issues is always an after the fact question. So that preventative component doesn’t come into it properly because we’re not sitting down designing a hospital extension or improving a model of care and going okay, we’re tearing it all down, we’re starting from new. Let’s figure out what our value points are and where we need to deliver impact and build from that.
Harry Iles-Mann (00:29:28):
There are a lot of people that live with Crohn’s and ulcerative colitis. I live with ulcerative colitis.
Harry Iles-Mann (00:30:34):
There are a lot of people that live with both of those conditions that aren’t as affected day to day. But the model of care as a scale doesn’t differentiate in terms of how it impacts each patient individually. There will be days where like today I can sit here and from the outside, I’m functional and a normal human being, for all intents and purposes. But there are other days where I can’t get out of bed.
Harry Iles-Mann (00:30:57):
So recognizing that you actually need to have a model of care that is built around the value system that’s dictated by a patient and what they want from their life and how they want to engage. Where do they want to work? What do they want to do? What do they enjoy doing? What are the things that by their life and through their day they define as the things that looking back on their day I go, I’ve had a good day and what are the things that stopped them from doing that?
Harry Iles-Mann (00:31:24):
And actually, centering our models of care around what matters to patients and not a point of origin of treating patients as the illness themselves. I think that’s really important.
Dr Charlotte Middleton (00:31:36):
What they want to achieve and what they’re hoping to improve on.
Harry Iles-Mann (00:32:17):
In an ideal world, I’d say we pull it all down and we build it all back up for purpose. And I understand that we just can’t do that. But there has to be a more novel and innovative and intelligent and sensible way of trying to retrofit and consolidate resources to eliminate where we know that we are wasting enormous amounts of money on treatment outcomes that are not eventuating inpatient benefits.
Dr Charlotte Middleton (00:32:44):
There needs to be that high-level recognition that what we’re doing is actually not working. And that is why we can’t tear it down and build it. We need to put change.
Natalie Raffoul (00:32:56):
I know we can start by bringing in quality of life measures or clinical indicators into some of these decision-making frameworks. So if you’ve been making decisions about policies or guidelines or management, or care models, bringing the quality of life that you just described into that so that we’re not just saying yep, did he have an event or not?
Natalie Raffoul (00:33:14):
Yes or no, did he get to a hospital or was he at home? And so I think, yeah, that would be complicated. But it adds to hopefully being able to individualize our approach.
Jane Calligeros (00:37:08):
I think Harry touched on it before as well. We just get presented with these new policies and initiatives and we’re not told anything else except this is what we’re doing now. And you’re scrambling to figure out what to do. I remember I was actually in primary health care when the care plan item numbers actually first came out years ago.
Jane Calligeros (00:37:31):
And there wasn’t any training or guidelines beyond the basic Medicare descriptions when they started in how we meant to provide care when we don’t know what the basics are of what we’re meant to do in those care plan appointments and things.
Dr Charlotte Middleton (00:37:44):
So I was just going to say my frustration around that, Jane is that that hasn’t changed. That still hasn’t changed.
Jane Calligeros (00:37:51):
It doesn’t matter. There’s nothing wrong with any of these programs. Sometimes I could do some tweaking. And I think that at a big picture level that care coordination of a patient has a really important role going forward. But if we don’t address the basic skills that clinics need to be able to run and a lot of that is with technology, if they can’t actually use the technology to start with then we’ve got bigger problems.
Professor Rosemary Calder (00:38:19):
I’d agree with that. I think one of our biggest problems is that we expect primary care providers to function as businesses to set themselves up into their own infrastructure to do all of the business organization and operation that we take for granted in retail community organizations and the like.
Professor Rosemary Calder (00:38:39):
But then we put handcuffs around their hands as well as cuffs around their ankles, I would suggest, by funding constraints, and we say you can only do this but not that. It’s not how our business operates. We’ve got the model upside down.
Professor Rosemary Calder (00:38:55):
And I do think it’s an imposition on general practice to expect it to better with what it still got in the way of its environment. Having said that, I think there are lots of things that within practices can be done better with the funding that’s available and the constraints that exist.
Professor Rosemary Calder (00:39:18):
And that’s what we’re really talking about today is what can you do now with what you’ve got? But until we really start to rethink the model of what it is we need in health care for the population’s well being and good. We’re asking general practice to do an awful lot with very little.
Jane Calligeros (00:39:37):
My background is actually like emergency nursing. So I spent the first five years of my nursing career in emergency and I remember seeing a lot of patients here and in the UK. Well, UK for nearly five years. So a lot of that time when patients came in from general practice at that acute level into recess and things like that, I’d be, “Well, what’s happening in general practice?”
Jane Calligeros (00:40:04):
And then so when I actually changed and when I came back to Australia, I went into primary health care, I actually started working in general practices and then you go, “Okay, I get it now. I get why things aren’t working.” You’re expected to be their expert and go-to for so many different programs and initiatives and things like that, that with a high staff turnover and no training.
Jane Calligeros (00:40:30):
There’s a lot of clinics that have never had formal training in the software they’re using, and they’re using multiple softwares to get through. Like reminder systems, third-party data collection. There’s so many things that they have to know and deliver care on so many different things now that you wonder why there’s a high turnover of staff, the high-stress levels.
Jane Calligeros (00:40:58):
There’s so many barriers and challenges that we face to get the chronic disease management even up and running. And the problem is, it’s a long time solution that we’re looking for. But a lot of clinics get frustrated and it just falls over and they give up. It’s just too hard. It just gets into the too hard basket and you can see why it’s hard.
Professor Rosemary Calder (00:41:27):
And now you said that I think there is recognition of that and as I said earlier, there’s a National Primary Health Care Reform Strategy or task force in place. Both governments appointed. There’s a National Preventive Health Strategy and Development.
Professor Rosemary Calder (00:41:47):
There’s a commitment nationally by health ministers to a National Health Literacy Strategy, which one would hope would go some way to resourcing individuals, as well as primary care providers, at least to help people know more about their own health and about the risk factors and modifiable and to seek help with those risk factors.
Professor Rosemary Calder (00:42:10):
So I think we’re slowly beginning to recognize that we are in the 21st Century and the world is a very different place. What’s lagging horribly I think is good use of digital information and digital technologies. And I think Jane’s mapped the complexity for general practice really well.
Professor Rosemary Calder (00:42:32):
So many different versions of data collection and data reporting and accountability that I don’t know how anybody manages it efficiently. And with the workforce that we have, the casualization of the workforce in keeping knowledge up to date and keeping efficiencies between multiple actors is very, very difficult.
Professor Rosemary Calder (00:42:54):
So we are asking an awful lot. And we do need to really put some effort into digital health information management for small business like general practice. But in the meantime, we have to think about how to develop the skills within the practices that stand so that we are using information better and our software more efficiently.
Professor Rosemary Calder (00:43:19):
And there is a bit of an onus when you are a business on being as good as you can be. And I think that’s an area where we can do more work supporting general practices to make the best of their business model.ADD IN FROM Dr Charlotte Middleton (00:34:44):
You might be aware, we have actually launched a new care plan tool here at MedicalDirector called MedicalDirector Care. Basically, it’s an integrated care tool. It certainly makes the completion of care plans a lot more efficient and provides a lot of very useful information to doctors and patients alike. There’s a lot of auto-population of things. So it’s makes it a lot more efficient.Harry Iles-Mann (00:43:33):
I think there’s also, in addition, that I think it’s a very good point that is made about running as a business in terms of the limitations and expectations is that if you think about any business that is not health-related, what you are doing is trying to sell an experience fundamentally, whereas the expectation is that a general practice sells a service.
Harry Iles-Mann (00:44:56):
I think there also needs to be a component that’s a rethink and government acknowledging that they need to properly resource general practice and primary care to actually provide an environment that offers a good experience for patients.
Harry Iles-Mann (00:45:26):
So that patients aren’t annoyed and short or irritated with staff at the front desk, who can’t do anything about the fact that the patient before them is taking 15 minutes longer to see their GP and cutting into their appointment time. That’s just how these things work.
Harry Iles-Mann (00:45:46):
But having an environment and methods of dealing with these things and creating an experience that is far more soothing and supporting for the patient, the grievances fall away, and what you’re left as a patient to focus on is the service that you received. And the service far a majority is a fantastic one.
Harry Iles-Mann (00:46:06):
And I think it’s the level of recognition for how high a quality service is provided is cut short because the resources aren’t provided well enough to actually support the experience component. So I think that potentially is another area that maybe not to the same degree of importance, but it’s also certainly a platform that you could build from as well.
Dr Charlotte Middleton (00:46:32):
I think so much of this is patient-driven. This is I feel is where a lot of patients are expecting a different way of us delivering medicine. They’re expecting that we’re going to be more up to date that we’re going to have preventive strategies and whatnot.
Dr Charlotte Middleton (00:46:49):
So I think a lot of that drive has been from the patient point of view. But that brings me back, to some of the technology because I feel like a lot of my patients are expecting that technology is going to be used in the practice. So things like wearables and things like that that we as doctors are going to start interpreting that or working with them on that.
Dr Charlotte Middleton (00:47:11):
Natalie, there’s a lot of cardiovascular wearables and things out like that. What’s happening at your organization with regards to that?
Natalie Raffoul (00:47:21):
Look, I think what we’ve seen is an absolute exponential increase in fitness and wellness and health-related apps. A lot of them do somehow take in the heart rate, all the way through the diabetes-related wearables. I think the jury is probably still out as it relates to whether or not these wearables will impact screening or can effectively screen particularly compared to the things that we have available at our fingertips in a medical setting. So the jury’s out on that.
Natalie Raffoul (00:47:54):
But there’s no doubt that the advent of these wearables means that there’s more information. Information whether it’s coming to the consumers or it’s coming to us or general practitioners in primary care. And the challenge will be how we use that information and potentially how we monopolize on it because I think I didn’t want to interrupt the flow.
Natalie Raffoul (00:48:16):
But I think one thing that we’ve mentioned a lot is resourcing. It’s an issue we don’t have enough of it. But I want to point out that one of the biggest challenges that we have and what we’ve experienced from our research at the Heart Foundation is that people are not even thinking about preventing their chronic disease. It’s not even salient to them. It’s not front of mind.
Natalie Raffoul (00:48:36):
So it’s not as if they’re all lining up outside their general practice and waiting for their GPs not servicing them properly. They’re just not engaged with their health until something happens. And so one of our biggest challenges is to get them to even think about how diabetes, CVD, chronic kidney disease could be relevant to them.
Natalie Raffoul (00:48:56):
And so there is the potential that these wearables could bring that to front of mind possibly, but no doubt, there’s a lot of information we’ll have to be able to navigate throughout that.
Jane Calligeros (00:49:14):
I was going to say look, unfortunately, the age group we’re trying to target is their most difficult target group to get into the clinic. And it’s not through any fault of their own. I agree wholeheartedly, they’re not standing at the door lining up to come in at that age group. That 40 to 49, 45 to 49, their heart health assessment for 45 and over.
Jane Calligeros (00:49:37):
That target group age is so hard to get into a clinic for so many reasons. They’re working full-time. They’ve got young families. They’ve got elderly parents. They’ve got so much going on that they’re last in the list of things to take care of in their day. And I think that has a really big impact.
Jane Calligeros (00:49:57):
So the patients that are readily available to come into a clinic are patients over the age of 75 or that are regularly into the clinic for other reasons based on their condition. So they come in regularly for scripts and other things into the clinic. And they end up in that chronic disease management cycle every three or six months into the clinic.
Jane Calligeros (00:50:18):
But unfortunately, the target group we want is really hard to actually pin down and it comes down to a lot of clever marketing to get patients in. So I’ve seen some great initiatives over the time that I’ve worked with different practices. They’ll send out the Ozeri diabetes in a birthday card for the patients turning 40 like Happy 40th. Fill this out and you could get a free health assessment at the clinic. Those kind of things.
Jane Calligeros (00:50:49):
You have to if they’re working Monday to Friday, 9:00 till 5:00, what are we doing as a clinic to open our doors up to these patients? Are we doing any late nights? Are we doing Saturday mornings? Those things to actually give them an opportunity to actually come into the clinic or otherwise, we’re just waiting until they develop a condition.
Jane Calligeros (00:51:09):
So it’s really tricky. But I do think that the wearables have an opportunity because gamification is very powerful with their health. So competing against yourself of how many steps I did yesterday to today, you get caught up in that bubble. I think it’s a good bubble to get caught up in.
Dr Charlotte Middleton (00:51:29):
I certainly think there’s other applications too that are definitely helping people manage once they have got a chronic care disease like medication management tools and the digital apps that we as doctors can literally prescribe that have been approved that can help with their day to day management. Emma, is there anything that you’ve seen in that area?
Emma Lonsdale (00:51:51):
Oh, I was just going to say, I think it’s really important that people feel comfortable to work with their GP using these apps. So there are health apps out there and they’re not all regulated. So we really don’t know what people are using. And you really don’t want them to not talk to their GP about what they’re using and what they’re relying on.
Emma Lonsdale (00:52:09):
So there are pros and cons. They might pay a bit more attention to their heart rate or something and it might be an incentive to go to their GP. But we want their communication to be open so they’re really talking to their GP about what they’re seeing and what they’re using. So they don’t just shove it behind closed doors and use risky software that we don’t really know.
Harry Iles-Mann (00:52:30):
I think one of the really important things with the wearable tech as well is that we do have a focus on underpinning it with the requirement that it is interoperable. Otherwise, effectively, all we’re doing is creating a new silo of health care for every single patient.
Harry Iles-Mann (00:52:47):
There will be a silo of health care for every single patient with a device that doesn’t communicate with any other devices that doesn’t connect to any overarching infrastructure that might not even connect to GP software for their GP specifically.
Harry Iles-Mann (00:53:02):
And we know how fragmented and siloed the system is already and the problems that’s causing this. But you imagine 27 million silos for every single person in this country and all of a sudden, you’ve got this problem that you never just going to get your head around solving.
Harry Iles-Mann (00:53:18):
To me, the idea of wearable tech as a management technology is a really exciting one. The benefit of continuous glucose monitors for type one diabetics, the introduction of that into Australia has been an absolute game-changer.
Harry Iles-Mann (00:53:36):
The willingness of the government to get on board and actually subsidizing that for people under the age of 21 has restored a quality of life and functionality to people that otherwise had very limited options moving forward in their lives. And for the most part, are now able to actually engage and connect normally with the world around them, which is such an important part of their development individually.
Harry Iles-Mann (00:53:59):
It’s a bit of a blue sky dream for me. But I would love to get to the point one day where potentially pathology can be done in a wearable way. One of the things that I personally have struggled with most is shortly after I had a surgery in 2010 to remove my large bowel, which its primary function is responsible for water absorption and keeping you hydrated.
Harry Iles-Mann (00:54:23):
And I spent the next 12 months in and out of hospital spending four or five days at a time taking a hospital bed just because I couldn’t figure out how much I needed to drink to stay hydrated. But knowing real-time what my hydration and what my pathological indicators of hydration were would mean that I could make a real-time decision, okay, I need to drink more water. Otherwise, I’m going to spend the next four days in a hospital bed which is expensive, and taking a bed away from someone who’s probably a lot more on well than me and actually needs it.
Harry Iles-Mann (00:54:57):
So I think there’s a huge potential there to introduce features in wearable technology that make it easier for patients with existing complex chronic health issues to manage it in a way that is not only accessible for them, but there’s continuity for them and it’s passive for them.
Harry Iles-Mann (00:55:17):
It’s not this active intrusion in their life. It’s something that just was a way in the background. I think that’s one of the challenges that we have in introducing new forms of digital innovation and innovation in care models is having to consider the question, fundamentally, is what we’re about to implement. Is this going to encourage or is it going to discourage engagement?
Harry Iles-Mann (00:55:40):
And if the answer is that it’s going to discourage engagement you know that you’re not heading down the right path with that. You want to be doing something that is getting people to connect whether that’s coming through the door or whether that’s just being more aware of and in control of their own health.
Harry Iles-Mann (00:55:55):
And I think as you very rightly pointed out, the awareness issue is a huge problem as well. We can’t begin to start marketing and selling the value of solutions when the majority of the Australian public doesn’t understand what the problem is in the first place. It’s a really, really challenging thing to get our head around.
Natalie Raffoul (00:57:37):
I feel that we have come quite a long way in learning about different ways to engage consumers and innovate. And you’ve brought up the wearables. I think to share the Heart Foundation’s experience something we learned over the last two years was surprise, surprise when you tell somebody that they have a 20% chance of developing heart disease. They say, that’s really not that low. I have a 80% chance of not developing heart disease. I’m pretty good.
Natalie Raffoul (00:58:11):
And that is classified as high risk. So we took on some of the literature and the guidance that’s developed in the US and also in Europe around heart age, which is based on the Framingham Risk Equation. So it’s still the same equation that sits behind the Absolute Risk Calculator.
Natalie Raffoul (00:58:31):
But what it does is it communicates that risk in a way that people can more readily understand. So instead of saying 20%. I say, actually, your heart age is 10 years older than your actual age. And it’s amazing. We’ve done some research and recently published on it. But we’ve done some research into the reactions that people have and most often, they’re quite shocked.
Natalie Raffoul (00:58:52):
Some people are happy if they get a good age, a lot of people might be disappointed. They might question the credibility of the calculator or how it reflects their life. But what we found is that no matter what their reaction was, whether it was very strongly bad or strongly good, down the track, they report making some changes.
Natalie Raffoul (00:59:12):
Because it was a hard truth. But down the track, they appreciate that maybe they did need to see their GP for that check that they’ve been putting up or putting off or check their blood pressure or whatever it may be. So I think we’re getting better at communicating these things, but we need to utilize the technologies and really involve the consumers in all of these decision-making avenues.
Dr Charlotte Middleton (01:00:37):
So I’m very much about trying to prevent disease and looking for the root causes and using nutrients and whatnot, where I can. And that having those conversations with my patients, they’re normally very receptive to, yes, let’s put some things in place. Let’s do our bloods. Let’s do some basic testing to see where we’re at.
Dr Charlotte Middleton (01:00:53):
So I do think there’s a lot of onus on us as GPs to be having those conversations with our patients and to be talking about prevention, not just here’s a pill to get rid of those symptoms and then on your way. So I think it’s all around. But I definitely agree, it’s not all doom and gloom.
Harry Iles-Mann (01:01:11):
It’s a big burden. It’s rightly so and I think often points unfairly, it’s GPs are considered the gatekeepers to the health system. And that is an enormous weight to carry. And I think, unfortunately, the public, the government, and the people that resource general practice and primary care, don’t afford it the same gravitas of resourcing as the label and expectation that they’re attaching to it.
Dr Charlotte Middleton (01:01:42):
Can I just quote you on that place? I really need to.
Harry Iles-Mann (01:01:44):
You’re more than welcome to.
Dr Charlotte Middleton (01:01:47):
That’s great. I look on that note, I think we are going to need to finish. Was there anything else that anyone wanted to add to the discussion at all? We’ve all said our piece.
Harry Iles-Mann (01:01:58):
I just want to quickly just on the point of data management. I think it’s a really, really important point to make. Because there seems to be or at least in my experience of engaging with clinical environments and public policy and governance, there seems to be this understanding that we don’t have enough data, which is not true. We have so much data. But the form that it’s in is not a form that’s conducive to being used.
Jane Calligeros (01:02:30):
Harry Iles-Mann (01:02:30):
I think it’s one of the most important ways that we can progress this. What most excites me is one of the areas where we are making the most progress is interoperability but incorporating atomic data so that we can actually take data sets. And we can do something with them that not only reflects and better manages health on a personal level but gives us a better big picture view of what’s actually happening out there in our communities.
Dr Charlotte Middleton (01:03:33):
That’s a magic word interoperability.
Harry Iles-Mann (01:03:36):
Dr Charlotte Middleton (01:03:38):
Professor Rosemary Calder (01:03:39):
And if I could add something, which I think is really important given the discussion this afternoon, and that is, yes, we’re awash with data. And we have software providers, such as MedicalDirector who are supporting practices in how they manage their data and what they need to know and how to use it.
Professor Rosemary Calder (01:03:58):
And Charlotte, you just talked about the educated doctor that you are and how you ask the questions about what can be done to improve health as a priority for you. How do we use the data we’ve got? How do we use the software capability that we’ve already got to resource general practices, not just general practitioners to do that to the best of their current ability?
Professor Rosemary Calder (01:04:24):
We’re not mining the resources we have in my view, and we could do it because we choose to take the leadership role and make it happen and demonstrate what can be done if only we had better system support. Instead of asking the system to be fixed, I think we need to take the lead and start doing what we can with what we’ve got and showing what could be better.
Dr Charlotte Middleton (01:04:49):
Right. Back to the drawing board. I couldn’t agree more. I couldn’t agree more.
Speaker 7 (01:04:55):
I’ve got one more question.
Dr Charlotte Middleton (01:04:56):
So lastly, Emma, I might just ask we know there’s a lot of alliances trying to work together for the common good. Could you just expand on that a little bit?
Emma Lonsdale (01:05:04):
Yeah. So I work for the Australian Chronic Disease Prevention Alliance. And it was set up more than 15 years ago because we realized that there are lots of chronic diseases that have the same risk factors. And everyone was saying different things and also approaching things slightly different ways.
Emma Lonsdale (01:05:21):
So we thought if we can all make sure we’re talking to each other, and we can advocate essentially for prevention with a shared voice. So really we’re focusing on preventing chronic disease looking at addressing risk factors, and how can we work together rather than all doing separate things rather than duplicating each other’s efforts.
Emma Lonsdale (01:05:42):
And we work as a group. But we also work with other organizations. I know Rosemary’s group as well, the Mitchell Institute. So involving lots of different health organizations so that we can have a greater impact together.
Dr Charlotte Middleton (01:05:56):
Fantastic. Excellent. That’s wonderful. Well, look, thank you so much to all of you this evening for being with us. It’s been a really fantastic conversation. Obviously, we need to watch this space. Hopefully, we see some more improvements over the coming years. But once again, thank you very much for your time today. Appreciate it.
Emma Lonsdale (01:06:17):
Harry Iles-Mann (01:06:17):
Thanks very much.