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Gold Coast General Practitioner Dr Katrina McLean is grappling with the impact of COVID-19 in her role as a provider of primary healthcare.

Like GPs across the country, she has suddenly found herself working in a dramatically changed healthcare environment; one where Telehealth consults have become the norm, onsite patient appointments now involve major coordination, and the testing of any of suspected coronavirus cases requires access to scarce Personal Protection Equipment (PPE) and the ability to ensure the case’s complete separation from all other functions of the practice.

“There have been a lot of changes to process,” Dr McLean tells me when I interrupt her patient list on a busy Friday morning for this phone interview.

“It has been a huge amount of work adjusting to a new way of managing how we deliver our services,” she says.

It seems the process has only been made more complex by the volume and variation of information being channeled to the medical community from various arms of government.

“As a GP I have certainly found trying to navigate what to do confusing,” Dr McLean offers.

“There is information coming out regularly from the Commonwealth Government and then, because of where my practice is located [Burleigh Waters on the Gold Coast], I am also needing to stay across the information coming out from both Queensland Health and New South Wales Health,” she explains.

“A lot of it is different too. Working across a state border, the challenges have been amplified — some patients need to apply for a permit to visit me.”

As the weeks pass and the Federal Government’s attack plan for slowing the virus’s spread sees the country transitioning to level two lockdown restrictions, Dr McLean admits she is learning to “accept the uncertainty” and muddle through.

Something she says she is grateful for is the inbuilt resourcefulness of her medical craft group.

“As generalists I think we are very adept at working in environments with limitations,” she says.

“We are flexible and readily able to adapt. I see my practice and others doing this — there is a lot of innovation happening right now.”

A definite positive to have come out of the pandemic, according to Dr McLean, is increased connectivity among GPs.

“I’m buoyed by the informal networking and experience-sharing that I can see happening between GPs and practices everywhere,” she says.

“It is helpful to learn about how others are approaching the various aspects of this situation as it unfolds and simply to feel connected to colleagues during such an uncertain time.”

Tuning in to Telehealth

In March the Federal Government rolled out its COVID-19 response package for primary care, including new MBS items for telehealth consultations, further bulk billing incentives for concessional patients and increased Practice Incentives Payments.

A shift to telehealth for a significant portion of General Practice consultations has highlighted both pros and cons to remote delivery of healthcare for GPs.

Dr McLean says her practice is definitely seeing some benefits while noting that GPs have actually been advocating for a model of care which incorporates elements of Telehealth for some time.

“For patients I know well it is proving very helpful,” she explains.

“I have a clear understanding of their histories, any current health conditions they have and can manage many of their needs effectively with a Telehealth consultation and follow-up,” she says.

“It has also meant reduced visits to the practice for patients who have difficulty accessing transport. Similarly, new parents and parents who are now finding themselves working from home and trying to manage children who are also learning from home are benefiting from not having to attend the practice for an appointment.”

However, there are, of course limitations.

Dr McLean says in her practice between 30-40% of patients still require face-to-face appointments for things like skin checks, minor surgical procedures, antenatal and newborn examinations, and insertion of long acting contraceptive devices.

“In many cases we are operating on a part telehealth/part face-to-face basis, whereby we begin with a telehealth appointment and progress to an appointment in the practice for the aspects that can’t be managed or investigated remotely,” she says.

As every GP will attest, there are a range of instances where Telehealth simply can’t replace the value of a face-to-face interaction and Dr McLean says she would be concerned if too much reliance was placed on this mode of delivery.

“There is definitely a risk of fragmenting care,” she explains.

“Since the government’s telehealth incentives were rolled out I have certainly noted an influx of telehealth providers marketing directly to consumers.

“Patients don’t have the same level of understanding and awareness as GPs do around the problems this fragmentation can create,” she says.

Mental health is also an area in need of monitoring, according to Dr McLean.

“Telehealth access to mental health services is beneficial, for sure, but it’s still incredibly important to maintain some face-to-face appointments,” she says.

“We simply can’t pick up on all the visual cues needed for a comprehensive mental health assessment via phone. Patients too are reporting to me that telehealth isn’t a great substitute.”

Aged care pressure point

Though it has received little to no media coverage since the pandemic began, maintaining the delivery of GP services to residents in aged care facilities has revealed itself as a pressure point.

Dr McLean explains this is an area where telehealth has major limitations.

“Aged care work has been challenging for GPs for some time because the staffing levels in our aged care facilities is notoriously low — something that has been highlighted in the Royal Commission into Aged Care Quality and Safety,” she says.

“A pivot to utilising telehealth and reduce face-to-face consulting times requires adequate nursing staff in aged care to support GPs.  We also really need a dedicated room to be assessing patients who need to be seen.

“Unfortunately both the staff needed and physical space requirements are seldom available. The staff are incredibly willing and want to help, but they are so stretched it really limits what can be achieved.”

Preventive health concerns

GPs take their role in improving patient health outcomes through preventive care very seriously, which makes the flow on effects of the pandemic even harder to bear.

Dr McLean notes she is very conscious that her ability to support patients with preventative health is greatly reduced right now.

“Patients may not be seeking out the care they need because they are fearful of venturing out to general practices or they are unsure about whether they can access certain services if they do go,” she says.

Childhood immunisation is an area of concern.

“We are worried people won’t be bringing their children in for routine immunisations and the possible ramifications of this; there is a real risk of something like an outbreak of measles occurring should significant numbers of children fall behind on immunisations,” she explains.

More public messaging from the government around general practice and other forms of primary care would be welcomed.

“There is anxiety in the community about what is and isn’t safe to do.

“Australians need to know that all GPs are working hard to ensure their practices are safe places for patients to attend so we can continue to provide care that can’t be delivered via telehealth.”

The domino effect

The domino effect of COVID-19 is being felt keenly in the world of General Practice.

Face-to-face consultations are down which means revenue is falling.

Dr McLean estimates revenue in her practice is currently down by 30%.

The flow-on effect of this, she says, is that many general practices are being forced to stand down valued nursing and support staff.

The Federal Government’s pause on elective surgery has put millions of patients in limbo and left GPs unable to progress specialist referrals and diagnostics.

Curtailed capacity to provide routine medical assessments within general practices represents another fallen domino.

Dr McLean highlights lung function testing as one example of this, with employers in a range of industries and groups such as volunteer firefighters feeling the impact.

“It is clear COVID-19 is going to be with us for some time, so the challenge for us as GPs is to try to monitor issues as they crop up and support our patients with strong continuity of care wherever possible,” she says.