Published in Sep/Oct 2020 BayBuzz magazine
While most of us in Hawke’s Bay could pretend life was (almost) back to normal during the short, sweet months of June and July post-lockdown, those working in primary healthcare were ever conscious things were different.
General practice had changed overnight on 22 March, and for many there could be no return to the pre-Covid status quo.
On Saturday 21 March, Royal NZ College of General Practitioners urged its members to move to a telehealth model, effective from 8am Monday 23 March, and all Hawke’s Bay general practices made that shift as Jacinda Ardern made history.
With only a small number of HB practices routinely using phone and video consultations, this meant most had to completely reinvent their services, from infrastructure (securing additional phone lines and tele-tech resources), to new models of care and infection control.
In the immediate, hectic days of lockdown there was very little national guidance, so each health organisation was effectively re-inventing the wheel, coming up with a safe system that worked for its purposes, and then making constant adjustments, with an agility not typically associated with general practice.
Rachel Monk, GP and clinical lead at Totara Health, for instance, took on the coordination of her centre’s Covid response, which saw her researching bleach ratios for sanitising benches, writing protocol, working with her team to devise a 6-day on, 14-day off rotation for in-clinic staff to avoid potential virus-spread, while adapting to a new way of practice and reassuring anxious patients.
In the first week, phone calls to the Totara Health reception desks quadrupled – from the usual 700 per day to 2,800; they had to triple their number of phone lines.
While the company had already invested in tele-tech for its Hastings and Flaxmere clinics, within 48 hours its entire 73-person team were capable of working remotely from home (and many did for the duration), including nurses whose routine, hands-on work had been halted.
Telehealth “is a bit of a Rubik’s Cube for general practice,” says Totara Health’s general manager Shane Gorst, “but Covid has forced our hand to make it work … From 99% face-to-face consultations, we went to 80-90% phone consults – overnight.”
Hawke’s Bay pulls through
People embraced telehealth because it felt the safe option. Or the only option. Or sometimes, because the prospect of being treated by a healthcare worker in full PPE was unappealing and they didn’t feel welcome, or didn’t want to be a nuisance.
But along with the shift to telehealth (with limited ability for GPs to recover co-payments), during Level 4 there was a sharp drop in consultations all round. ACC “disappeared”. Subsequently, overall revenue dropped by 30-50% – half of HB general practices applied for the Covid-19 wage subsidy; most reduced their opening hours, some their service.
But although there were reports nationally of general practices folding, it appears in Hawke’s Bay, so far, all made it through. Totara Health is justifiably proud to have managed to navigate the situation without a single staff member losing their job or an hour of pay.
While there has been concern that telehealth would further entrench the inequities in access to healthcare, a survey conducted by the PHO (Health Hawke’s Bay) during lockdown, found that Māori and Pasifika consultation rates in the region did not drop as much as for the non-Māori/Pasifika population, indeed, one practice commented that Māori and Pasifika were amongst the best adopters of virtual consultation modalities.
Gorst says, for some of Totara’s enrolled patients (especially mums with young kids), telehealth has meant “a sudden and significant improvement” in access to healthcare services.
Level 1 normality
Initially, during alert levels 4 and 3, booking in-person appointments was at the doctor’s discretion (and contrary, to public perception, in-person consults when clinically required were on offer across all practices, according to the PHO), but as alert levels went down, people became more vocal about wanting more choice.
Practices are now trying to find the balance that works best for their cohort of consumers, while adjusting systems to meet both health safety measures and the practicalities and idiosyncrasies of their particular service models. From what I can tell, this varies enormously between practices.
Two months into Level 1, and offering patients the option between in-person or phone consults, Totara Health (the largest provider of GP services to Māori and Pasifika in Hawke’s Bay) reported a consistent 50-50 split between the two – half of their consults are, by patients’ choice, via telehealth.
At Hastings Health Centre, on the other hand, while the practice continued to offer virtual/phone consults as an option, the overwhelming pattern (during Level 1) was a return to face-to-face appointments. When I spoke with Dr Alan Wright on 13 August, he said, very few GPs at HHC had been doing phone consults the week before.
Dr Cormac Fitzgerald says Taradale Medical Centre (which offers three options for consults: phone, virtual and in-person – the preference for 85%) has been busier than before Covid, “Once we went down the levels it was full steam ahead, because people sat on their symptoms, essentially. They’re now coming in with a shopping list of problems.”
Busyness across the board is corroborated by every receptionist I speak to, often belied by the sparsely-peopled quiet of waiting rooms.
In many cases, patients at TMC are directly emailing their GPs. It’s not something most practices encourage, and some of Fitzgerald’s colleagues feel swamped, but he finds it useful. “In the past we were doing things through a filtered-down process via reception staff. There’s maybe more paperwork now but less appointment time, it’s cutting down work in the long run.”
Positive outcomes
From the conversations I’ve had with GPs in Hawke’s Bay, there are a number of positive outcomes to emerge from the Covid response, the most oft-quoted being: increased collegiality and collaboration across primary and tertiary healthcare, and both within and across districts; the move to e-prescribing; better management of patients through a telehealth triage system; and a culture change around illness.
There was a profound sense of collegiality during lockdown as medical professionals rallied together, with a different ease and transparency of communication between primary and tertiary care. For example, a Facebook group was set up for GPs and specialists, senior hospital consultants, nurses, where regular broadcasts were shared and specialists were able to directly answer generic questions about problems, cases. “We felt like we were on the same team,” says Dr FitzGerald, “and even now it feels like we’re more on the same page than before”.
Dr Wright reflects: “From a primary care point of view, one of the key learnings was how much was achieved when we worked together. The CBACs [community-based assessment centres] were very much a cooperative effort across the board, and between Hastings and Napier there were daily communications, cooperative planning and implementation, in a way that hadn’t been done before. Out of this response it was clear, we can work seamlessly together when we want to.”
Electronic prescribing was “an amazing thing that happened out of Covid,” says Dr Monk, while Wright affirms, “nobody would ever want to go back to paper-prescribing again.” It saves a huge amount of time, not only the labour of handwriting in instances where handwritten prescriptions were previously required, but by emailing prescriptions directly to chemists, it bypasses reception staff, freeing them up too. “E-prescribing was always in the pipeline,” Monk explains, “it just happened to get a hurry along.”
The success of drive-through flu vaccine clinics during lockdown is also mentioned as the “way of the future”.
The implementation of a telehealth triage system in those practices (like Totara and TMC) that have transitioned to the Health Care Home model (a patient-centred approach for doing more with less) has been especially effective for fast-tracking acute cases and for managing patients – GPs are enjoying more control over this.
While it varies from practice to practice in set up, basically patients are put on a call-back list, and in those initial calls the doctor assesses the situation, and either resolves clear-cut issues then and there (such as prescription renewals) or plans for consultations that are tailored accordingly (whether that’s phone, video or in person). It’s only the consults themselves that are charged.
For Dr FitzGerald it means he can work out ahead if someone requires a longer appointment and slot them in before a break, for example, or if they’re going to need blood tests there’s latitude to pre-plan. “There are a little less surprises now.”
He also speaks of a culture change in practice – “It’s now inappropriate for staff to come in with a cough or cold”; they’re taking sick days and feeling able to do so, whereas in the past they would have soldiered on. Many practices also continue to run separate respiratory clinics. At Totara, Shane Gorst says segregating patients with flu symptoms is now the new normal – “that won’t go back”.
Downstream effects
Not all general practices have managed the situation well, however. One GP I speak with in early August on condition of anonymity has just resigned from her job – “Covid was certainly one of the straws that broke the camel’s back,” she says, “It’s been chaotic and messy and very stressful.”
She cites poor communication, and feeling disconnected from her colleagues and the workplace itself both during the period of remote-working and in the scrambled, uncertain aftermath of lockdown. Stress around job security has been an issue (the practice asked staff during Level 4 to consider reducing hours as a way to recoup costs) and shorter opening hours means she doesn’t have the time she usually would at the end of the day to catch up on paperwork.
The wider issue though, “is dysfunction within a dysfunctional healthcare system,” and she worries about the downstream consequences of lockdown, the effect on mental health, the already long waitlists for surgeries, for treatments, the way patients are often “mucked around” – “that weighs on you”.
Dr Monk says she’s not surprised to hear of resignations – “burn-out rates for doctors are high”. Not only is there big, unmet need in the community, hospital issues (often due to lack of funding, staff and services) fall back on GPs too, necessitating repeat referrals and increasing workloads, which coronavirus has only compounded.
She says when she first started out 16 years ago, her daily caseload was more of a mix between the simple stuff (like coughs and colds) that might take 5 minutes to resolve, and the more complicated – accordingly there was some time flexibility to juggle it all. But increasingly, nurse practitioners, paramedics and other health clinicians are dealing with the easier-to-resolve issues, and with Covid she’s not seeing respiratory patients at all because they’re being separated off. “Now it’s just back-to-back, complex cases” that she struggles to fit into the 15-minute consultation blocks the government funding system provides for.
Monk has observed an increase in mental health issues since March. “While there were already a lot of people struggling with mental illness before Covid, there does seem to be an upsurge … We’re definitely seeing the impact of Covid on people’s wellbeing.” [This is something BayBuzz will be looking closely at in our November/December issue.]
For her personally, working on the frontline of the coronavirus pandemic has been “emotionally exhausting”. She describes herself as naturally change-adverse, and yet Covid saw general practice capitulate to rapid, ongoing change, which six months on is still unfolding.
Things can change overnight
When I interview Monk on day 102 of zero community transmission in New Zealand, with more prescience than she can possibly anticipate, she notes that a Covid outbreak could happen any time, although with all systems in place for such eventuality, hopefully with less disruption. “The situation could change tomorrow, but I don’t lose sleep over that now.”
That very evening the government’s emergency Covid alarm bawls from our phones to announce the new outbreak in Auckland and swift level 2 and 3 restrictions.
As it happens, at noon on the day we step up the alert ladder again, I have a booked, in-person consultation with my own doctor in Greenmeadows. My temperature is taken at the door, the usual scripted questions, Perspex screens at the counter. The waiting room here is fairly full, and a few wear masks, but the atmosphere feels almost convivial. Quite different from the wary, on-edge vibe I experienced back in March.
This time we all know the rules of the game and how to play them. It seems we’re adapting to some kind of Covid normal. A certain philosophical acceptance of uncertainty, heroic participation in what, initially, are some pretty weird rituals, the ability to turn on a dime. What this new normal looks like in the fullness of time, however, is yet to be written, as well as the ongoing implications, both positive and negative, of a still evolving pandemic.
Telehealth
Telehealth encompasses the gamut of phone and virtual communications, and it was already being used to some degree by general practice in Hawke’s Bay (i.e. secure messaging via patient portals), with government incentives to engage in teleconsultations. But Covid fast-tracked the process for all.
“We know that overseas, teleconsultations are working well,” says Dr Rachel Monk, “but this is very new for most NZ doctors, and we were thrown into it very quickly.”
Consequently, there’s still a lot to learn and work through, for health practitioners and consumers alike.
What’s apparent is that telehealth is here to stay. We won’t be going back, I’m told, to face-to-face appointments only, though it won’t supplant these entirely either.
Here are some of the pros and cons, as experienced in Hawke’s Bay:
Pros
• It’s quicker than coming in to see a doctor (factoring in travel and wait-times, a 15-minute appointment takes up, on average, an hour of your day), and you’ll ‘see’ your GP within 48 hours.
• It significantly improves access for those who face barriers for going to a GP for an in-person consult (such as difficulties with transport, childcare or work arrangements).
• Some people are more comfortable using modern technology than meeting with their GP face-to-face, for some it’s just less of a hassle.
• GPs have more control over their day and how they manage their patients – it allows for a more planned approach to consultations.
• A practice can ‘see’ more patients in a day than they could otherwise in the traditional in-person service model.
• Reduced wait-times for booked, in-person appointments.
• More flexibility – both in time and approach.
Cons
• It tends to work best when there’s an established in-person relationship first (knowing the patient) – it’s trickier with new or casual patients.
• Not everyone’s enrolled, or even knows their GP (in some bigger practices, staff turn-over is high), which precludes the above.
• Some patients feel cynical about the adequacy of the medium; it doesn’t suit everyone.
• There’s more uncertainty for doctors in making over-the-phone diagnoses; and it’s no substitute for instances where a visual, physical exam is preferable.
• It’s difficult to manage some things, like chronic illness and mental health issues, over the phone – here video consults would be better, but as yet are not always viable.
• Available video consultation platforms, such as Doc See Me, are ‘clunky’ and not easy to use, and they rely on technology and data that not everyone has access to.
• The current funding model for general practice – premised on 4x standard 15-minute in-person appointments per hour – doesn’t cater to modern tech modalities or service demands.
Going forward, the government is investing a further $20 million to improve telehealth capacity within general practice and community health providers (i.e. more tech resourcing). Health Hawke’s Bay says it’s identified some barriers to, and consumer concerns with, telehealth locally, and is working with the Consumer Council to develop best practice guidelines. The Ministry of Health recently announced a sponsored data partnership with Spark, Vodafone and 2degrees, meaning consumers using these mobile networks can access essential health information, resources, and online health services, such as patient portal Manage My Health, for free (no data charge).
But ultimately, the way general practice itself is funded – based on a historic service model that pre-dates digital and mobile communications – is going to have to be addressed. “The vulnerability of this funding model was exposed during Covid-19,” says Health Hawke’s Bay CEO Wayne Woolrich, “and this has reinforced our position that the funding model for primary care requires a significant rethink.”
Photo: Florence Charvin. Dr Rachel Monk, GP and clinical lead at Totara Health, Hastings.