ACC wants to work differently with General Practice.
From 11 February to 5 March 2019 we held a national roadshow to open the conversation with the primary health care sector and key stakeholders. The conversation focused on how we could build a partnership based relationship for future working with General Practice.
199 primary healthcare professionals attended 17 sessions in 13 different locations around New Zealand. These sessions identified several issues providers face with the current way of working with us.
Have a look at the key themes we identified from your feedback at the roadshows and let us know if we’ve got it right. You can also download a copy of the full roadshow summary report at the bottom of the page.
Skills and capability
This is what we heard from the roadshows on how we can achieve better outcomes by complementing your skills and capabilities:
- Nursing input is generally seen to be undervalued in the current regulatory model. A lack of joint consultation between Nurse Practitioners and Practice Nurses means teams are unable to take full advantage of the considerable skill and experience nurses offer.
- General Practice is being progressively "deskilled" in acute care under the current funding model, as there is little incentive to provide this care. Patients are routinely referred to hospital or after-hours services.
- The interdisciplinary nature of the wider General Practice team should be reflected in our terminology. Referring to practitioners, rather than GPs and Nurses, will build confidence in our view of the General Practice team.
- We need to view the patient as a whole person with individual medical and social needs, not just a person with an injury. We need systems that take advantage of the General Practice team’s in-depth knowledge of the person in a high trust, low bureaucracy model.
- At times we question clinical assessments and require diagnostics, which may not be clinically indicated, e.g. a clinical diagnosis of fractured ribs after clear history of direct impact injury. In this example, we asked for the patient to be x-rayed to confirm this assessment which undermines trust.
- The role General Practice teams often play in co-ordinating return to work or stay at work. There is a need for us to better utilise the potential for General Practice to lead recovery.
- Nurses and General Practitioners want more training and education opportunities on identified topics. You suggested delivering this via video or online modules with the ability to earn CME points.
- PHOs add a great deal of value to process around clinical quality, peer review, and education.
- There are differing levels of knowledge and skills amongst those in the same profession which should be recognised, i.e. General Practitioners with Special Interest, Nurse Prescribers.
We understand there are a number of ways our working relationships can be improved:
Relationships with ACC
- When interacting with us you would prefer a single point of contact, ideally someone who you get to know and trust. Many of you told us of the value added by previous relationship management roles such as the former GP Liaison role within ACC, which is no longer in place.
- We need to trust that you know what is best for the patient.
- You highlighted ongoing frustrations in communicating with us – particularly the formality of communications and lack of any ongoing relationships that would build trust and confidence.
- There are preconceptions and/or a lack of trust when dealing with us arising from experiences with cover decisions, inconsistent communication around patient entitlements and care plans, and onerous administrative burden.
- We do not always work collaboratively with the wider health sector and do not sit cohesively as a part of the patient’s overall journey.
Relationships with Others
- Collaboration needs to occur between all practitioners contributing to a patient’s care, as well as with us to ensure the patient receives the best possible outcome.
- General Practice often lack visibility of patient care and outcomes with other providers in the community, e.g. Physiotherapy. Often General Practice teams are unaware a patient is being seen by allied health professionals, particularly if they present there in the first instance. There was a suggestion of building a requirement for patient progress reporting between providers into contracts. You'd like to pursue options for leveraging existing systems and enabling solutions such as electronic shared care records.
- ACC Accredited Employers and Third-Party Providers can be difficult to deal with.
- If PHOs are involved in an alternative way of working, we would get the best value from a relationship with PHOs around quality and education functions, rather than claims management.
You've let us know our current funding models need to be more flexible and better reflect the type of work involved in patient care. Here's what we heard:
- There is inequity in current schedule rates between General Practitioners, Nurse Practitioners, and Nurses, and no joint rate for Nurse Practitioners and Practice Nurses.
- Vocationally-registered General Practitioners are not paid the same as other specialists.
- The rate for providing clinical notes has not been updated for many years and does not adequately remunerate the time, particularly for large requests.
- The fee-per-visit model does not always reflect the work involved and the way the care is provided.
- Integrated ways of working could be adopted to enable a collaborative, patient-focused approach to service delivery in primary care, such as Health Care Home, Health Hub and Integrated Family Health Centres which are not supported by the current fee-per-visit model.
- Increased resources and inputs required to manage complexity are not recognised.
- Those with PTSD and patients with sensitive claims often need intensive management, which is not adequately remunerated.
- Limited flexibility when a patient presents with multiple or complex injuries in a single appointment, needing to see multiple practitioners with varying lengths of consults. Managing claiming for multiple injuries and multiple visits is challenging.
- Telehealth (including phone contacts) is not an option under the current model.
- The concept of more flexible funding, such as introducing funding for a “service” (similar to the Rural General Practice contract model of payment for time spent, regardless of clinician), rather than a fee-per-visit per practitioner “rate” was viewed positively.
- Capitation models were discussed as unfavourable options due to the variation in resources required to treat a variety of injuries.
- Particular interventions, such as wound care, are not adequately funded under the current model and there are no best practice guidelines around the use of particular dressings.
- You would like to see funding that recognises practitioners operating at the top of their scope, or with specialised skills and experience within their profession.
Systems and operations
This is what you thought about how we can improve our systems and operations to better work with you:
- You are keen to see us explore models that would enable more secure and easier exchange of information via channels such as HL7 messaging.
- It can be difficult to get hold of Case Managers by phone and many are not keen to share their email addresses. Practitioners sometimes feel they are in an information vacuum.
- There is frustration with us requesting the same information multiple times, i.e. clinical notes. You would like us to explore use of systems like KonnectMed to enable electronic upload of clinical notes.
- General Practitioners are expected to sign off return to work for patients under the care of other community providers. Sign off for return to work should sit with the practitioner who is leading the care, with any return to work plans being shared across practitioners.
- We should make better use of our data to provide feedback on outcomes and the uptake of pathways as it becomes available.
- Our coding system to diagnose patients’ needs an overhaul – we need a more consistent model that is easy to use.
- You gave us details of many issues with the ACC18:
- There is a mandatory notes field on the form that does not display to our staff at all.
- As a web-based form, if you are adding free text notes and close the page or go back, all the notes typed are lost.
- No ability to “park” or save a form for later.
- It would be ideal if there were integrated health records that everyone could access. You suggested HealthOne as a good example of this in the health sector.
- You told us that our systems do not account for public holidays, which can negatively impact on a patient’s recovery when their claim is declined as no practitioners are available to provide information.
- Our website is difficult to navigate and its search function is lacking.
We gained valuable insight into how we can be more patient centric, this is what we learned:
- We need to take a holistic view of the patient and treat the whole person, not just an injury.
- We need to empower General Practice teams to manage people with complex needs. The current model does not enable flexible management of more complex cases, particularly around sensitive claims and those with PTSD.
- Our consumer workshops need to capture the views of individual patients and not focus on organisations. Patients with the most critical feedback may be reluctant to engage and may “suffer in silence”. It’s important to provide opportunities for them to share their experiences.
- Practices see and know the patients, so are best placed to know what would help them achieve the best outcome.
- A great deal of goodwill exists in the system with practitioners going above and beyond for their patients. Our way of working needs to be supportive.
- The current regulatory model requires face-to-face visits for all interactions, which means patients must be brought into clinic for funding to be accessed by the practice. This does not value the patient’s or practitioner’s time, creates challenges for patients who may have transport and social issues, and generates an unnecessary financial burden with patient co-payment for appointments.
The roadshow suggested a number of new health models for us to consider, here's what we heard:
- A number of initiatives and models underway within the heath sector (that have proven to add value) were mentioned as possible options for us to consider. Physiotherapists embedded within schools, return-to-work programmes for those with chronic health conditions and utilising Green Prescription were all mentioned as examples of approaches that dovetail with injury management and prevention in primary care.
- There was discussion on how bundled payments or packages of care could work and the associated risks. These approaches could work well for wounds and non-complex injuries, but may not be so effective for more complex cases, such as a spinal injury.
- Overall practitioners were supportive of General Practice teams playing a bigger role in injury prevention.
- Injury prevention at a population level could be achieved in a similar way to the current falls prevention approach, although the use of DHBs for delivery was questioned.