I have a dilemma.
Improving the health of Australia’s first nations people, Aboriginal people across Australia, and Torres Strait Islander people from islands off the north-east tip, is a national priority. One of the main mechanisms of doing this is to perform a health check. In fact, so important are these health checks that Aboriginal Health Services, as well as regional and national health bodies, are measured on the number of health assessments that they do.
Fortunately for the services (and GPs, who are often paid on a percentage of their billings) Aboriginal Health Assessments pay well, and can be thought to subsidise the complex care that pays less well. Fortunately for the patients, an Aboriginal Health Assessment allows access to a number of sessions of allied health funded through a rebate from Medicare, which is really important for access to care for a group of patients who are often unable to pay. There is good awareness of health assessments in Aboriginal and Torres Strait Islander communities, and people regularly attend services requesting their health check, and sometimes get rewarded with unique T-shirts.
The problem with this approach is that there’s no evidence that health checks are beneficial. Two systematic reviews have shown no benefit on mortality.1,2 Perhaps it works in a population group at higher risk of dying early, particularly from cardiovascular disease. Again, sadly, the evidence is not encouraging.3
So my dilemma is a familiar one. Should I be doing these health assessments? All the carrots and all the sticks in the health system are geared towards promoting an intervention that probably doesn’t work. Like many interventions, it probably seemed a good idea at the time, and it’s been built to provide funding and access to health services for a group of people who have had poorer funding and access than other Australians.
Perhaps it’s not surprising that health checks themselves don’t work. The only way they can possibly work is with good follow-up of any problems identified — essentially to be part of longitudinal, relationship-based care. Decisions about interventions and behaviour change will be done in partnership over time, not just in a single assessment. Medications will be monitored, titrated, tinkered with. People will be supported through smoking cessation, dietary changes, or grief. There will be advocacy for better housing, or to be treated as human beings by welfare agencies. None of this happens in a single assessment visit.
This is how I solve my dilemma. I’ll take the funding and I’ll take the access to allied health, and I’ll use the health assessment as a ‘getting to know you’ exercise, where I get to know about the things not on the health assessment template — where the patient is from, their family, their passions, their hopes. I’ll listen to their challenges, and of course we’ll discuss their medical conditions and treatments, and how these affect what they want to do in life. They will also get to learn a bit about me and how I work, and get to know some of the people in the service with me.
There’s never an objection to this approach. This is exactly how patients want us to use these assessments.4 Too often my patients have had poor experiences in health services. Giving people positive experiences of health care should be just another routine part of our work — navigating well-meaning health policy and adapting it on the ground to make it work in some way for our patients.
- © British Journal of General Practice 2021
