Collaboration between health care professionals is recognised as a key strategy for effective care of patients with chronic disease.1 Multidisciplinary care planning involving general practitioners has been associated with improved outcomes for patients with chronic conditions.2 Care plans grew out of experience of the coordinated care trials, which aimed to optimise outcomes and resource use and were based on the principles of the Chronic Care Model.3 They were designed to coordinate care across multiple providers and involve patients in setting goals that can be achieved over 12 months, at least in part, by self-management. Subsequently, the Medicare arrangements were modified so that patients who had had both a GP Management Plan and a Team Care Arrangement (TCA) could access up to five visits to allied health professionals over 1 year under Medicare. These have been actively taken up by GPs and their patients. In 2008, there were 679 400 claims for Medicare Benefits Schedule item 723 (TCAs), at a cost of about $68 963 877.4

Despite some modifications in 2005, GPs have continued to voice discontent with the complexity of current arrangements for TCAs.5 In a viewpoint article in this issue of the Journal, Hartigan and colleagues argue that TCAs are too restrictive and cumbersome to achieve their aims (Hartigan et al).6 Certainly, care plans involve a complex series of steps, including confirming eligibility, performing a GP Management Plan, getting agreement from other providers to participate in a TCA, documenting the goals and services to be provided, giving the patient and other providers a copy of the care plan, and submitting a claim to Medicare. In response to this complexity, many GPs use care plan templates, which, although they involve goal setting and patient engagement, may result in care that is insufficiently tailored to patients’ individual needs.7 GPs and patients feel that they have to negotiate these hoops for the purpose of accessing allied health services, which may be otherwise unaffordable to many patients with chronic conditions who are on low incomes. The process is often perceived to be more of a “paper chase” than an effective means of communication and coordination.8

Written care plans developed as part of a TCA may also contribute little to improving relationships between GPs and allied health providers.7,9 Negative referrals, where patients present to their GP requesting a TCA to access an allied health provider, are particularly annoying to GPs. Engaging state community health services also remains problematic because of different funding models and possible disagreement with the GP’s priorities.10 The limitation of five allied health occasions of service is frustratingly inadequate for patients who have truly complex comorbidities.

Despite all this, the idea of team care still has merit. The traditional referral system works well for medical specialist care where a single consultation is sought or the specialist is taking over primary medical responsibility. However, it is not appropriate for most allied health care, or care by medical specialists where this continues to be shared with the GP over time. There is general acceptance that GPs are well placed to coordinate primary medical care, as they can provide the continuity of care needed for coordination and engagement of patients.

Establishing effective communication between team members is critical to establishing trust and clarifying roles and responsibilities.11 This has not been effectively addressed under the current TCA system. Although it provides incentives for engagement of other providers, the lack of personal interaction means that these relationships may remain weak. Even with simplified arrangements and support for networking between GPs and allied health workers, the process could still be time consuming, especially if patients are to be actively involved. Engaging other members of the practice is essential. Many practice nurses are involved in helping develop and implement TCAs, and would like to expand that role.12

The evidence of the effectiveness of TCAs is quite limited. Multidisciplinary care plans appear to be most effective with higher-risk patients, such as patients with poorly controlled diabetes rather than those whose diabetes is relatively well controlled.13

So how can the process be more functional (Box)? Many of the problems arise because of the fragmented nature of our health system and the attempt to use TCAs to control access to other services. There needs to be more emphasis on communication and on ensuring quality of care and access to a comprehensive range of care appropriate to needs. Ideally, patients could be registered on a shared database, with other providers contributing dynamic information. This would obviate the need for “paper shuffling” and allow more time for one-on-one interpersonal communication over the phone to negotiate priorities for each patient.

This may also allow a more flexible approach to governing access to allied health services. In the United Kingdom14 and the United States,15 levels of care are based on the level of risk of hospitalisation. GPs have demonstrated that they can assess a patient’s level of risk and that this is acceptable to patients, although it requires additional time.16 However, the federal–state split in the Australian health system means that shared assessment is difficult. GPs need to be able to initiate and negotiate access to care according to need, rather than an arbitrary number of sessions.7

More broadly, a greater focus on development of teamwork between providers and more support for self-management is needed. Although large, integrated primary health care services may provide an opportunity for this, for the foreseeable future, providers will have to work together across distances and organisational boundaries. This does not happen by chance, but requires active facilitation.17 There is a potential role for Divisions of General Practice to facilitate formal and informal links between general practice staff and allied health providers — for example, as part of continuing education programs and in developing shared care guidelines that delineate the roles and responsibilities of providers.

TCAs are a mechanism to support effective patient care. However, the challenge remains for health professionals to negotiate goals for individual patients and to communicate more effectively with each other. Care planning may be useful in facilitating more collaborative care and better outcomes for high-risk patients13 and those with complex needs. This function is impeded by procedural complexity and funding rules. Although we cannot agree with Hartigan et al’s radical prescription to replace TCAs with patient summaries,6 we agree that there is ample room for improvement in the current process.