Complexity of primary care warrants new approaches to patient safety

We must heed the lessons of failure.

You could not have missed it; Australia is currently experiencing the impact from decades-old perfunctory approach to patient safety in primary care. The Royal Commissions into aged care, opioid related deaths from managing chronic pain, hospitalisations from medication adverse events and investigations into complementary therapies have all been prominent headlines over the past few months.

Complacency has drifted across Australian health governing bodies where the political focus has been on cost management rather than patient safety. Our professional oversight processes have also not kept pace with the complexities of care that some patient groups now require. Similarly, the business of health has not always kept safety in the forefront of their health services.

For a health system that desires “patient-centred care” as its prime principle, we have paradoxically cultured a primary health system that is very indifferent to patient safety. It is time to make patient safety a health policy priority and redesign our primary care systems accordingly.

Safety was probably a policy after-thought in primary care

To understand these safety failures in primary care, it is worth reviewing some of the key precedents to the harms developing.

In 1997 the Aged Care Act was introduced and repealed the legal requirement for 24-hour nursing care in aged care facilities. Regardless of concerns raised, role substitution ensued to save costs and nurses were replaced by less skilled staff. New funding models were created for general practice which stifled GP attendances at aged care facilities and reduced continuity of care. For our most complex patients, management plans replaced care, drugs replaced staff, and quality became a series of tick boxes on a checklist. Multiple subsequent “reviews” into the sector were ignored.

And now, we are at a Royal Commission because of patient safety issues. Driving cost reductions by reducing professional oversight is a hazardous practice.

The Pharmaceutical Benefits Scheme (PBS) has delivered medication to Australians for over 70 years. The rapid expansion of therapeutic options to treat disease, the increasing complexity of patients’ conditions and fragmentation of care has led to significant challenges in managing safety of individual patients. Now, approximately 2-3 per cent of all hospitalisations are due to medication adverse events. Whilst less than 50 per cent of these are preventable, that leaves a significant number of patients harmed from medication.

Whilst the PBS has delivered medications, it has not delivered medication safety for patients despite a multiplicity of medication reviews, pharmacist interventions, medication reconciliation or meds checks. As recent experience with codeine and increased dispensing medication quantities have shown, the business of pharmacy appears to have higher priority than patient safety.

Depending on old systems to solve modern problems is proving ineffective. Reform of the pharmaceutical benefits scheme to deliver patient safety is essential.

In the 1990s several medical publications questioned the problem of pain under-treatment; they argued “pain relief was a patient right”. Even though the problem “pain under-treatment” was never quantified, pharmaceutical companies marketed opioid use as a professional and compassionate treatment option; pain as the “fifth vital sign” was promoted and accepted, performance metrics for pain management were introduced. Despite lack of evidence and known clinical concerns, many well-intentioned patient, nursing and medical groups supported the movement for increased opioids for pain management. Opioids grew into the primary modality of chronic non-cancer pain. There were few monitoring systems in place to clinically monitor this potentially serious change in practice. State and Federal responsibilities were neither clear nor appropriate in ensuring public safety.

And here we are, in an opioid crisis, with record levels of patient opioid related deaths. Lack of strong clinical governance in primary healthcare has allowed commercial interests to drive health care.

Regulatory bodies have a primary role in protecting the public from the actions of unscrupulous practitioners or unsafe practices within their respective fields. Health businesses have used “patient rights to choose their health care” as a mantra for delivery of inappropriate therapeutic options. Chiropractors are still treating infants without any evidence of benefit. Chinese herbal medicines get special treatment from the TGA to circumvent therapeutic honesty. Somehow it has become acceptable for drug companies to provide direct to patient “health services” in pharmacies; your prescription from a doctor is now used to on-sell more drugs and services; vitamins and other substances are being advertised as lollies (vita-gummies) for children.

The necessity for “evidence for health care benefit” has been ignored. Regulatory laxity has resulted in patients experiencing irrelevant health advices, and the subsequent safety impacts. To what extent should marketing and alternate care influence consumer health care choices, particularly those consumers with low health literacy?

And here we are; the medical board undertaking a review to regulate medical practitioners who provide complementary and unconventional medicine and emerging treatments. We should applaud this activity but ask why this hasn’t occurred across all primary care providers.

The safety problems we are now experiencing in primary care were mostly foreseeable and certainly preventable. Inappropriate commercial influences, lack of regulatory oversight, failure to implement clinical governance, and absence of appropriate clinical monitoring all repeat with monotonous regularity.

The examples above are by no means comprehensive; additional concerns have been raised about childhood mental health, inappropriate preventive health screenings, “too much medicine”, the proliferation of transgender health interventions and antimicrobial use. More recently drug companies and pharmacies have been pushing “increased access to medication” by down-scheduling many drugs on the PBS. This is to allow drugs to be advertised and sold over the counter without prescription. There is no evidence that society is suffering from any lack of “access to medication”, but it suits government who are keen to reduce medication costs and it suits businesses who wish to improve profit streams. The red flags of decreased professional oversight, lack of evidence of benefit, drug companies driving health policy, lack of monitoring outcomes are all there.

A collaborative strategy is needed

In the past, primary care was considered the poorer cousin to hospital care, but the clinical landscape of primary care has changed significantly with more complex patients being provided increasingly sophisticated care. The basic assumption of relative safety of primary care arena has been exposed to be misleading. We are well past the tipping point for clinical change to support patient safety.

Will we learn anything from these reviews?  History suggests we will not.

It is certainly concerning that the aged care review did not review the political contribution to the problem, just as pre-election announcements confirm pharmacy funding is more important than patient priorities. No-one wishes anything less for cancer sufferers, but medication related harm is important for society too, yet medication safety hardly rates a mention. Similarly addressing the problems of unconventional medicine has not made the electoral radar compared to the old election chestnut of “waiting lists” for hospitals.

If we are honest about providing a health system that puts patients in the centre of care we again need to start designing our primary care systems to support the primacy of patient safety. That may just have to start with patients working collaboratively with General Practice to force a change in political priorities.