Back in the saddle

Well, have been a bit hectic the past few weeks since getting back to Kangaroo Island after my year away doing anaesthetics in NSW. Thankfully it's relatively easy to slip back into the groove of rural medicine - and in fact it's been a welcome relief after being back in the tertiary hospital system. But still had to get used to running on time, all the paperwork that seems to swamp us as well as catch up with friends and family back home.


Hence no blog posts since early January.


However today I am on call, sitting on the deck with a 12 month old kangaroo that Trish has taken on board in my absence, watching the rains over the north coast of KI.


Being on call again is actually quite refreshing - the Kangaroo Island doctors as a whole are now doing three weeks out of every four on the EM roster...the remaining (4th) week covered by a Country Health SA locum. I believe similar arrangements have been in place elsewhere in the State, where local doctors are struggling to fill the EM roster. Meanwhile between four of us we are providing full cover for anaesthetics and obstetrics, with two doctors doing each discipline.


I've also been getting to grips with delivering anaesthetics on KI - two lists so far which have been uneventful, although I'm still trying to work out how to make the anaesthetic machine display a minimal alveolar concentration of anaesthetic agent, and struggling with an end-tidal CO2 monitor that reads in unknown units (3.5-4.5 seems the average, not the 35-40mmHg I'm used to). One for the hospital to work out...


When not at work, I have been analysing the results from the GP-anaesthetist survey - over 370 responses so far, and a fair proportion are dedicated GP-anaesthetists as well as 'occasional intubators' (rural docs who are on an EM roster and may be called upon to intubate seldomly). Results have been interesting, with no surprises that rural docs don't have access to a lot of the airway kit that would be taken fro granted in the city. More worryingly, a session at the local (mostly volunteer) ambulance station last week showed me that they've got some kit on the ambulance that we don't have in our hospital! Had some helpful insights from airway giants like Paul Baker (NZ) and Minh le Cong (RFDS Qld), as well as lots of comments from the wider GP-anaesthetist cohort who seem to share similar frustrations as we do locally. But more on that later, as I polish my manuscript and hope to get published later this year. Meanwhile, will try and give a few talks during the year to interested parties.


But back to on-call....I've realised that it's been almost two years since I've done an EM shift on Kangaroo Island - away for all of 2011 doing anaesthetics and for 2010 the docs on KI were reeling from all the nastiness over contract negotiations with Country Health SA and the ACCC. Now I am on-call for anaesthetics for half the year and doing one emergency shift a week....and wondering where we are at with contract negotiations - the last contract was due to end Nov 2011, rather than the usual three years...as rural docs were generally unhappy with the contract terms but were prepared to accept an interim contract hoping things would improve.


Back on 30/11/11 the head of Country Health, Belinda Moyes, wrote asking for a three month extension to contract negotiations. That extension is due to expire on 28/2/12 and I've not heard peep from Country Health over contracts. One has to wonder if they are serious about negotiating a new contract, or will just keep 'extending' the current contract rather than negotiate.


A big issue for me (and many other doctors) has been the sheer unfairness of Country Health insisting that people presenting to the emergency department are billed privately by the on call doctor, unless they are admitted to a hospital bed. This seems plainly unfair - whilst patients in metro areas are treated for free in the Emergency Dept of public hospitals, their country cousins are charged. 


Many of these services are for things that are not routine 'general practice' ie: X-raying a fracture and setting a limb in plaster, suturing an extensive laceration, pulling a dislocated shoulder back into shape, dealing with an alleged rape or victims of a motor vehicle accident. Country Health has managed to formalise this in the most recent (well, in fact the first) contract from 2010 with a clause stating that:


"non admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from Medicare). For the avoidance of doubt, CHSA shall not be liable to pay any fee for such services"


Their rationale is that such patients are an extension of the doctors private practice. Indeed, CHSA states that:

"This funding model with MBS being paid for public patients attending state hospitals, is acceptable to the Commonwealth due to an exemption in the National Healthcare Agreement that ‘in those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor.’ 

As far as I know, South Australia doesn't have an exemption under the National Healthcare Agreement but continues to obfuscate this issue. What really twists my melon, and that of the patients who I see who are charged for their attendance, is that they have neither requested treatment by their own GP, nor is there treatment part of continuing care or a prior arrangement with the doctor. Basically, it's not a private service...it's just Coutnry Health SA cost-shifting dollars from State to Federal expenses.

In fact, the on call doctor is called to attend patients in the ED as part of his/her role as the doctor on-call for emergencies in a contract with CHSA. There is no prior arrangement, they are not private patients and usually this is not part of continuing care.

Quite how the Health Department continues to get away with this blatant cost shift from State to Federal (Medicare) coffers amazes me. And it is cold comfort to our patients - the rural ones are already disadvantaged enough, and the metro or interstate ones are flabbergasted to be charged fees for services in ED that they would receive for free at home. And of course the overseas tourists (and we see a fair share on Kangaroo Island) are less than impressed to receive a bill and aren't covered by Medicare.

Bottomline, the doctor on call for emergency medicine for CHSA doesn't get paid to come and see emergency patients, unless they are admitted to hospital for over four hours...

Let's hope this issue will be resolved in contract negotiations - although with two days to go until contracts expire, I am not optimistic.