Medical services provided by general practitioners in residential aged-care facilities in Australia

The importance of aged care is growing substantially with the increase in the number of older people in our society. This trend will continue, with the number of people aged ≥ 85 years projected to increase from 1.5% of the population in 2004 to 6%–8% by 2051.1 Along with an increase in the number of elderly people in Australian society, there has been a steady increase in the number of people living in residential aged-care facilities (RACFs). At 30 June 2005, an estimated 7.3% of people aged ≥ 70 years were living as permanent residents in RACFs.2 Although nurses and personal care attendants provide 24-hour supportive care to residents of RACFs, general practitioners are the main providers of primary medical care. The current primary care medical model leaves the medical care of each resident to his or her independent GP, who, in many cases, will not have formal links with the RACF.3 The purpose of our article is to review the current status of GP clinical activity in RACFs and the impact of current initiatives to enhance access by RACF residents to these services.

We searched the English-language literature indexed in MEDLINE, the Australasian Medical Index (AMI), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Rural and Remote Health database (RURAL), AgeLine, and government and other reports of research projects in aged care conducted in Australia up to January 2007. Over 400 publications from peer-reviewed and non-peer-reviewed sources were identified using the terms “Australia”, “general practice”, “general practitioner”, “GP”, “primary health care”, “nursing homes”, “aged care” and “residential aged care”. The publications were examined independently by two reviewers, and 22 were selected as being relevant to our study objectives.

Statistical data were obtained from publicly available sources including Medicare Australia, the Australian Bureau of Statistics and the Australian Institute of Health and Welfare.

Data extracted from Medicare Benefits Schedule (MBS) statistics for the financial year 2005–064 indicate that the predominant service provided by GPs to residents of RACFs is a standard consultation. Standard, after-hours and public-holiday consultations together comprise 96.5% of all medical services provided in RACFs (Box 1). The remaining items comprise services related to Medicare rebates that have been progressively introduced by the Australian Government to facilitate better access to GP services as part of its Enhanced Primary Care (EPC) program.

Medicare data show that between 2000 and 2005 there was an increase in the provision of complex services to patients in RACFs. For example, complex consultations of Level D (items 51 and 96) increased by 67%. There has also been an 18% increase in the number of all services provided per GP since 2000.5,6 In 2005–06, an average of 12.8 GP services were provided per occupied aged-care bed, amounting to an average cost to Medicare of $570 per occupied bed per year. This is substantially higher than the average of 4.5 non-specialist services per whole patient equivalent in 2005–06,7 with expenditure of $239 per patient in 2005–06.8

There is a growing concern reflected in the literature that GP services to RACFs are inadequate to meet current needs. A 2004 survey of GP availability in RACFs found that 52% of RACFs sometimes had difficulty obtaining GP services for existing residents, and 56% sometimes had difficulty obtaining GP input for routine services such as writing and reviewing medication charts and prescriptions.9

We identified the following barriers to provision of GP services to RACFs:

• Low levels of reimbursement. GPs perceive that the level of reimbursement for their services to RACFs is lower than for routine clinical work in their surgeries.10,11

• Time-consuming processes. Increased demands on GPs — with the paperwork required for RACF residents12 and, quite often, unnecessary and time-consuming transposition of clinical data — make visits to RACFs time-consuming and leave GPs with little time for contact with the patients themselves.

• Younger GPs have much lower rates of providing services to RACFs than older GPs. RACFs are becoming increasingly reliant on an established cohort of older, predominantly male GPs who themselves may soon be reaching retirement age (Box 2).6,13

In response to these challenges, a variety of incentives and programs have been initiated by the Australian Government and state health departments to facilitate GP activity in RACFs. These include the Aged Care GP Panels Initiative, the EPC program and expanded palliative care programs.

With the ageing of the population and consequent increase in the number of people requiring care for multiple and complex conditions in RACFs, the role of GPs is prominent as a primary source of medical services. However, we have identified several ongoing barriers to the provision of GP services to RACFs. Initiatives to increase GP access — including improved reimbursement, participation in Aged Care GP Panels, and an enhanced role in palliative care — appear to be having an impact, but it is too early to determine whether they will be sufficient to meet the rapid projected growth in this sector. Additional research is needed to investigate the potential impact of innovative models of care and alternative funding methods.

2 General practitioner visits to residential aged-care facilities (RACFs), by age of GP*

* Expressed as rate per 100 GP visits. Adapted from data from the Bettering the Evaluation and Care of Health study on general practice.13

3 MBS claims relating to Enhanced Primary Care items in residential aged-care facilities (RACFs)*

MBS = Medicare Benefits Schedule. * Data from MBS statistics.4