Dr Tony Lembke retired as the Chair of the North Coast Primary Health Network in December 2018. He looks back at his time with the various primary health care support organisations from the early 1990s until today.
Not long after I joined the Alstonville Clinic as a fresh young GP in 1993 my senior partner Paul Earner suggested I put myself forward to join the Board of the newly formed Northern Rivers Division of General Practice.
I think his precise words were ‘Make sure they don’t bugger things up’.
The Lismore Base Hospital Department of General Practice was already very active at this time, and nearly all the Lismore and Alstonville GPs were VMOs. More than half the patients admitted to LBH - including obstetrics - were under the care of GPs. We all tended to run into each other each day on the wards, and every week we met at breakfast in the hospital cafeteria. On the menu was cold toast, bad coffee and a clinical presentation.
The new Division of General Practice had members from further afield - Ballina and Byron and Kyogle and Bonalbo and Casino and Evans Head and Coraki and Ocean Shores and Nimbin. The first edition of GP Speak was in November 1994 . This journal reminds us that the management committee at the time comprised Hilton Koppe, David Guest, Chris Mitchell, Jane Barker, Christine Gestier and myself. David Helliwell ran the Nimbin Drug and Alcohol Service, Brian Witt managed the Early Intervention for Alcohol Abuse program, and Hilton Koppe ran the inter-practice visits program. We should do that again! David Guest was responsible for IMIT, and we were famous for open source principles and promoting Tux the Linux penguin.
Our mission was to make it easier for our GPs to deliver the high-quality care they aspired to. This has remained a core goal during the various iterations of the local primary care organisations that have followed.
The Division organised educational events and social occasions. Do you remember the car rally to Broken Head, the weekend events at Couran Cove, the family event at Sea World?
The Division became the Northern Rivers General Practice Network (NRGPN). It was instrumental in the computerisation of general practice, where the North Coast is still a national leader. It supported immunisation and accreditation. Our region had the largest participation in the Australian Primary Care Collaboratives, which fostered innovation and collegiality.
We realised we were all dealing with the same issues and learnt to share generously and steal shamelessly. We ran the Family Care Centre in Lismore, managed the Nimbin General Practice, and auspiced the establishment of Bullinah and Jullums Aboriginal Medical Services. GP Speak became a voice of the local medical community.
Among many, Katherine Breen Kurucsev - whose tremendous skill and wisdom I remember her very fondly - Chris Clark, Sue Page and Andrew Binns were especially important to the Division.
From General Practice to Primary Care
In 2011, the government ceased funding General Practice Networks in favour of larger primary care organisations - Medicare Locals. 128 Divisions became 62 MLs. Medicare Local contracts were awarded to independent companies to provide specific services on behalf of the federal Department of Health.
The NRGPN, in partnership with our colleagues in the Tweed Valley, Mid North Coast, the Hastings Valley (and North Coast GP Training) and Many Rivers Alliance formed the company ‘Healthy North Coast’. We were successful in a competitive tender to manage this new entity.
The NRGPN was able to retain funds that it had acquired independently on behalf of the general practice community and has been able to continue to operate since that time. The long-lasting GPSpeak is one of its ongoing achievements.
The Medicare Local, owned by the community and clinicians, has the aim of ensuring each person could access the care team that they need, that this care would be of high quality, and it would be joined up. I believe that because the Medicare Local in our region was auspiced by general practice it was better positioned to retain a focus on grass roots care centred around the relationship between a patient and their GP. This was not always the experience nationally.
In 2015, 62 Medicare Locals became 31 Primary Health Networks. We were successful in retaining our boundary and in retaining management under the auspices of the company Healthy North Coast. This transition required a considerable amount of focus and a loss of momentum. I hope that the PHNs will now be given the space to consolidate their roles.
The PHNs have funding to support general practice and other primary care providers, and also to promote local integration of health care. They have a very specific role in assessing local needs and in commissioning services to meet those needs.
A Seat at the Table
A major result of these organisational changes is that general practice and primary care now have an established seat at the table where health decisions are made - in Canberra, in Sydney and especially locally.
The model of the Person Centred Health System, centred around a ‘medical home’, is well established and accepted at the highest levels of state and federal government. In this model, a patient and their family have an ongoing relationship with a particular GP, supported by a high functioning general practice team, and the rest of the health services wrap around this partnership.
Patients experience ‘joined up’ care. Our region has been instrumental in advocating for this model, and it is finally becoming rare for state and federal health strategies to ignore general practice.
In our region we now see joint planning between the Local Health Districts and the PHN. The Winter Strategy resources general practices to be proactive in managing high risk patients, supported by the Northern NSW LHD. We have a Healthy Towns program that is bringing together primary and secondary health, local council and social providers to develop innovative solutions to local needs. We are at the forefront of models for shared investment between state and federal governments, private companies, and social services, including education and justice, and other community services.
There are now regular meetings at every level - board, executive and management - between the LHDs and PHNs - and I cannot imagine any major initiatives that would not be a partnership. This is unique nationally.
Vahid Saberi and Dan Ewald require special acknowledgement for their vision and passion in developing the PHN. And I’I have had the honour of working with Linda Muscat, Leanne Tully and Marika Ilic for the whole 20 years!
Our second jobs
The first job in health care is the face-to-face interaction that clinicians have with their patients. What a privilege.
The second job is to improve the systems that enable us to deliver care, such that the next patient has a better outcome and experience.
It is easy as a doctor to think that the only one doing any real work is oneself.
I have developed a tremendous admiration and respect for those clinicians and non-clinicians who work in this second role - many of whom are part of the PHNs and LHDs. I understand that this ‘second job’ - success in improving systems - is just as essential in achieving our health aims as the role of clinicians.
Engaging with busy GPs was one of the greatest challenges for the Division of General Practice, and remains even more so for the PHN. I am aware that many GPs considered the Division a waste of money and the PHN even more so.
Progress is slow, many of the achievements are behind the scenes and not ‘branded’; frustrations have not been fully resolved; and systems are incomplete. It is easy to notice when things don’t work and it can be invisible when they do - when a discharge summary doesn’t arrive it stands out, yet is invisible when it does.
When I look at how I practice now, compared to when I started, some of the greatest successes that have been supported by the Division/PHN would include:-
Practice nurses are an integral part of the way we deliver care, forming a three-way team with GP and patient. They have more independence, and we wouldn’t manage chronic disease, wound care, immunisation and acute illness without them. They have a strong supportive network, and are forming cooperative teams with community nurses.
I started in a paper-based world. It is surprising to remember how poorly we tracked medications and patient summaries, and the amount of work in writing letters, repeat prescriptions (especially for nursing homes) and processing incoming letters and results. Discharge summaries are now timely and legible. A central health record is available, and the hospital has begun to upload key results and events. I can communicate with a patient’s care team electronically - for the most part anyway. This is still a work in process.
Mental health has become a highly significant proportion of the care we provide. We have many more tools at our disposal, including youth health services such as Headspace, psychologists, suicide prevention support services and geriatric services. Unfortunately, as the demand is growing, and being identified, there is much more to do.
Chronic Disease Management
CDM now makes up more than 50 percent of general practice. We have become much more proactive, systematic and team based. We have resources available to us in the community that facilitate the real work - that done by our patients and their families at home.
It seems to me that improved systems and better workforce has given us more time with our family. Certainly the after-hours load is much less, and we have more days allocated off each week.
People in our community need better health care. Our clinicians want to work in a system that enables them to deliver the best possible care. Our nation needs care to be efficient and effective.
I believe the NRGPN continues to have a vital role and I particularly acknowledge the work of David Guest, Nathan Kesteven and Andrew Binns as custodians. I think we had more collegiality as GPs and medical specialists 20 years ago and the NRGPN remains well positioned to foster our coming together socially and to guide professional development opportunities.
The NRGPN has an important role as one of just a few ‘owners’ of the PHN, and clinicians have the opportunity to participate in the clinical councils or as special advisors in the commissioning process.
The funding available to the PHN is an order of magnitude higher than that received by Divisions of General Practice. More than $20 million is available each year for commissioning the services that our community needs. As clinicians I believe we have a responsibility to ensure it is allocated effectively and efficiently for the benefit of our patients.
With our participation, we can build a Person Centred Health System by ‘focusing north’. Underpinning every time we see a patient, every meeting we attend, every paper and email we write, every service that is commissioned lies the question: how will this activity change the way an individual person uses their hands, feet or mouth to create a richer, more meaningful life for themselves?
Tony Lembke was an RMO at Lismore Base Hospital 1990-1992. He has worked at the Nimbin Medical Centre, Lismore Clinic, and Keen St Clinic. He has been a partner at the Alstonville Clinic since 1993. He was a director of the NRDGP 1994 - 2012, serving as chair from 1999. He was inaugural chair of the North Coast Medical Local (2012-2015) and then chair of the North Coast Primary Health Network (2015 -2018). He was a director of the Australian General Practice Network and the University of Sydney’s Donkey Kong champion in 1993.