Every year eventually becomes the year for the older person

Case conferences demand a degree of organisation that does not occur easily in general practice

Does anybody remember that 1999 was the International Year of Older Persons? Does anybody remember the statement made by Bronwyn Bishop, as the Minister for Aged Care at that time, titled “Our commitment to Australia’s seniors”?1

There were two pages on enhanced primary care and three pages on residential care, much of which was devoted to aged care challenges in rural Australia. Individually, some of the proposed recommendations were very sensible. However, the problem with so much of government rhetoric is in joining up the points to form a coherent whole.

Medicare payments are based on general practice being a one-to-one episodic consultation. Chronic medical conditions in an increasingly ageing population demand reliable communication between health care professionals. “Multidisciplinary” is one of those words beloved by the ministerial scribes; however, in the way primary care is structured, it is difficult to organise because general practice is based around doctors not multidisciplinary teams.

The Medicare item for case conferences, introduced in 2000 by then Minister for Health and Aged Care, Michael Wooldridge, for general practitioners and consultant physicians acknowledged that teamwork is an essential part of chronic disease management. However, case conferences demand a degree of organisation that does not occur easily in general practice. Interestingly, they do provide a means of supporting teaching as part of the service commitment.

In 2000, Wooldridge also established the Medical Specialist Outreach Assistance Program (MSOAP) with the aim of broadly increasing visiting specialist services in rural and remote areas and in so doing increasing and maintaining the skills of the local health professionals.

The traditional method of communication to the specialist is the referral letter from the GP, who waits for a response. The case conference demands a consulting specialist and a GP with a variety of carers being in the one place at the one time, either face to face or by video or telelink; importantly, the doctors must see sufficient value to set time aside for such conferences, insulated against other pressures.

Wooldridge had provided a funding mechanism for the Bishop rhetoric.

However, it was about joining the dots.

Richard Whiting is a consultant geriatrician who, until recently, headed the aged care services at Western Health, Melbourne, with a commitment to multidisciplinary treatment of the elderly. In North East Victoria, after a significant lack of an effective visiting consultant geriatrician service was identified, MSOAP funding was secured so that Dr Whiting could visit both Cobram and Yarrawonga, two towns in the Moira Shire in North East Victoria, each of which had health services and nursing homes.

Dr Whiting was able to test the value of the case conference and several of the GPs were prepared to participate. As for the nursing staff, case conferences with allied health professionals are a normal part of patient care, and their participation was relatively easy to maintain. However, after a promising beginning in 2007, this stand-alone program with one specialist who had a full-time responsibility elsewhere ultimately became unsustainable.

The incoming federal government in 2007 introduced funding for “superclinics” — funding buildings in the expectation that they would provide a complete one-stop primary health care service. This initiative attracted controversy because, although it seemed a good idea in its conception, it was little more than a “thought bubble” in its execution.

However, Cobram was well placed to take advantage of this program as the health service already owned its medical clinic. The chief executive officer and the Board were prepared to invest in the federal government model, yet without being recognised or rewarded by government funding for Cobram’s foresight — at least initially. However, with the relevant services under the one roof, working together was made easier, thus providing a base for the geriatric service.

In any program, it is helpful if the local doctors have a sense of ownership. In the case of aged care, the assumption of many government grants is that GPs universally have an interest in geriatrics; and that is not so. Local doctors with nursing home patients often just want the difficult patients referred or transferred to the local regional hospital for treatment of acute episodes because dealing with multiple comorbidities and determining how far to pursue a particular symptom is a challenge to any clinician without formal training in geriatrics.2 Being required to attend at a nursing home for such episodes interferes with the GPs’ other commitments. The consultant geriatric service inter alia aimed to significantly reduce the number of acute episodes and provide more formal geriatrician backup for the local clinicians.

Thus, there were barriers that had to be confronted when the decision was made by the Moira Health Services to apply for a grant from the Victorian Department of Health in 2011 to establish a visiting geriatric service on a firmer basis than the first iteration. At the time, there was no regular geriatric visiting service and the consultant geriatrician position at Goulburn Valley Health had been vacant for several years.

The previous program, which involved only Dr Whiting, was thus placed on a firmer footing after the Moira Health Services’ successful application for the program grant in 2011. The opportunity was taken to define the terms of agreement for participation of Western Health to provide visits by another consultant geriatrician, in addition to Dr Whiting. During the 3-day, 6-weekly visits, the particular visiting geriatrician — often accompanied by the registrar — also provided a lunchtime lecture at each health service venue. These lectures, on topics as diverse as “hoarding” and “polypharmacy”, were particularly appreciated by the nursing staff.

In 2011, a UK-trained consultant geriatrician, Dr Arup Bhattacharya, was appointed to the vacant Goulburn Valley Health position and he immediately saw the value of providing a visiting service and the benefits of combining teaching with service.

Therefore, when the funding from the Victorian Department of Health ceased at the end of 2014, the program has not only been maintained in 2015, but expanded. Dr Bhattacharya visits three of the Moira Health Services regularly. Dr Whiting continues to visit Yarrawonga Health and the three campuses of Alpine Health have now been added to the program. Funding for the consultant geriatrician visits is derived from the modified visiting medical specialist assistance program and from Medicare. The level of acceptance in the program has been shown to work for the local medical profession, such that (a) the original scepticism has been allayed and (b) the program has been received enthusiastically by the nursing staff.

This program has not been part of any grand design — hence my narrative. Elements of government policy have been fashioned for needed services, which fit into the words expressed in the Bishop statement back in 1999. It is now time to take stock — so much effort has been put into getting this one regional service for the elderly. The question is, has it been worth it? Is it time to evaluate the program? Is it sustainable? What is the appropriate balance between service and education? With what can this program be compared?

Later this year in November, a symposium is being organised in Wangaratta where those who have been involved and those who have an interest in the success of such programs will be invited to answer these questions. The answer may be that this is a combined service and education model that should be rolled out.

In 1999, Bishop was not yet a senior; today at 72 years of age, former Speaker Bronwyn Bishop remains an active member of the workforce. However, the ability of the nation to fulfil the fine words in her statement 16 years ago will become of increasing relevance to her as it is for the 15% of the Australian population who are over the age of 65 years.3