The Guardian 22 February, 2006
The hidden dangers
of "telephone triage"
Dr Con Costa
While public health services continue to crumble, proposals have now been put forward for a national hotline that will allow nurses to assess sick people over the phone. This is yet another attempt by politicians to cover the lack of services with low cost gimmicks — rather than properly funded health care.
Telephone triage will only increase the pressure on the public health system. The nurse on the other end of the line will almost always have to advise people to seek medical attention — to cover themselves and the patient. There are also inherent dangers in people delaying seeking first-hand medical intervention by instead phoning the hotline, especially the sick and the elderly. And yes, "people will die".
Making a diagnosis over the phone is difficult at the best of times, a "second best" system which should only be resorted to when there is no other service locally available e.g. the Royal Flying Doctor Service has been providing an excellent service to remote areas of Australia for years.
But it would be almost impossible for a national health hotline to give practical, local advice when you may calling from Adelaide and the call centre may be based in Brisbane (or even Delhi, where the rates will be much cheaper, and where there may even be some spare nurses!).
"Sorry our books are closed"
The proposal is being floated at a time when there is a desperate shortage of doctors, nurses and hospital beds. At present, many Australians cannot access a family doctor, much less one that bulk bills. When people ring the doctor they are often told: "sorry our books are closed" or "there is no appointment for three days"!
What advice do you give a mother with a child suffering a mild asthma attack in Adelaide from a call centre in Brisbane when: a) there may be no doctor available in her area or there is a three-day wait for an appointment; b) the doctor no longer makes house calls or wants a hefty up-front fee to visit at home; c) the doctor refuses to bulk bill and the mother has no money to pay.
People are told they should not attend busy public hospital A&E [accident & emergency] for minor complaints "because it gets in the way of more serious cases". Does she wait until her child becomes critical so he or she can be taken straight to hospital?
The fact is that governments have cut public health funding and reduced the medical and nursing workforce to unsustainable levels while diverting literally billions of taxpayer dollars to the private health system by such means as the private health insurance rebate.
The private system does not provide acute care, accident or emergency work but trades almost exclusively in profitable elective surgery. In fact, the private sector goes to extreme lengths to avoid those that are really sick, i.e. those who will probably end up using the hotline. And just like the proposed medical hotline would, the government funded Private Health Insurance Rebate is putting more pressure on the public hospital system — not less.
The existing small number of doctors now "grows fat" on ever increasing government "incentive payments", even while their ability to provide a comprehensive service (such as a short waiting time and house calls) declines proportionally. The number of house calls made by GPs has dwindled to one tenth of the number being made when the Coalition came to power in 1996.
On the night before Australia Day I saw an ashen-faced and rather unkempt looking 40-year-old who had been wandering around for the past six weeks feeling real crook. He was a bit yellow and his belly was swollen and full of fluid and he also had swollen, red, infected legs. He had obvious liver failure.
He was struggling to stay at work (he runs his own business) and upset that: a) he had just been waiting three hours at the public hospital and was being ignored; and b) he had seen at least two GP’s over the last few weeks, both of whom had given him antibiotics and sent him on his way.
They didn’t even bulk bill which further irritated him, not just because he would be out of pocket around $30 each time, but because it also meant he would then have to find the time to wait two to three hours in a queue to get some of his money back at the Medicare office.
How would telephone triage have sorted out his problems? He needed long-term care from an interested GP, hopefully that bulk bills and has a nurse employed in the practice, as well as a quick short-term admission to hospital to manage his liver failure, leg infections and possible septicemia.
Yet faced with continuous federal government cutbacks to public health, many health professionals (in and out of hospital) no longer seem to care. GPs are increasingly disinterested in looking into complex problems and the staff at hospital casualty departments are always "too busy".
Question of survival
They have become demoralised and tired from over work, unable to respond in a caring professional manner. Their survival instincts have taken over — and that means pushing patients through with quick revolving door medicine (quicker and sicker) whilst avoiding at all costs patients who may need a lot of time or, even worse, those that may need home visits or regular care in the home.
Under current federal health policy, a GP can sit in his or her office and maximise their income by seeing patients quickly and then performing a "Health Care Plan" (meant for someone with a chronic illness) on patients they may have never seen before and may never see again — and on whom they have no intention of making a house call should the need arise.
Government restrictions on places for medicine at universities means that existing GPs have become an exclusive club, able to pick and choose the patients that will provide the best Medicare rebates as well as multiple incentive payments, which can earn them up to quadruple the money on any one patient visit.
GP incomes are now at record levels while patient service and satisfaction is at an all time low.
By keeping GP incomes very high the Federal Health Minister encourages GPs to bear silent witness to the destruction of the public system. The Health Minister’s actions are akin to the captain of the Titanic taking care of the crew while leaving the passengers — including the elderly and children — to go down with the ship.
Setting up a national hotline will mainly benefit the rich and well educated and those who already have access to adequate health services. As an alternative for people without private insurance, access to a bulk-billing GP or nearby public hospital or for house-bound elderly and disabled people — i.e. those in most need — it simply won’t work.
It is window dressing, which will prove dangerous as it has the potential to put more pressure — not less — on the health system as well as the very real possibility of unnecessary deaths because of confusion, misdiagnosis or just unnecessary delay.
Better to put the $40 million towards paying for salaried nurses in general practice. But then again, where would we find the nurses given the existing chronic shortage and an unwillingness of young people to take up an overworked and underpaid profession?
One way would be to abolish the private health insurance rebate and using the billions of dollars thus saved to train more doctors and nurses, to adequately fund and staff hospitals, increase the nurses’ salaries, improve their working conditions and provide GPs with nurses. This course of action will relieve the pressure on the public health system.
Con Costa is National Vice-President of the Doctors Reform Society
and works in general practice in Sydney’s inner west.