In Australia, up to 2.3 million people are involved in informal care of children, adults and older persons with disabling chronic and terminal conditions.1 Their role includes managing medications, therapies and medical emergencies; providing supervision and emotional support; and assisting with personal care, mobility and household tasks.1-3 While caring can provide considerable satisfaction and strengthen relationships, carers often feel exhausted, isolated and burdened by their responsibilities.1,3,4 In a recent survey of carers, 58% reported their physical health had been adversely affected, a third said they had sustained a physical injury, and over half reported depression, anxiety, high levels of stress and other impacts on their mental health.2

There have been many calls for general practitioners to be more proactive in addressing the support needs of carers,3-6 and carers have identified how this may be accomplished (see Box).

A 1998 editorial on family carers in Australia3 called for strategies to raise health professionals' awareness about carers, to keep them abreast of programs available to carers, and to encourage them to be more proactive in helping carers to obtain support. Since then, there has been limited apparent progress in Australia (unlike Britain, where there has been considerable interest in the primary care team's designated responsibility for addressing carer needs7).

Projects conducted through Divisions of General Practice to inform and educate doctors, to promote carer self-identification and discussion5-6 and to promote collaborative referral with regional carer respite services5 showed encouraging outcomes, but have failed to attract further funding from government.

Carer associations have also acted by providing various resources. The GP information kit, Carer Checklist and Carers Profile assessment tools (trialled in New South Wales) are time-efficient and pave the way for discussion of carer issues.7,8 In Victoria, individual carers are encouraged to raise issues and to give their GPs a tailored service-provider kit, but this approach lacks systematic coverage. In South Australia, a GP working group is seeking to collaboratively explore various approaches, including GP education and involvement of practice managers.

Government initiatives have focused on raising GPs' awareness of community services and referral pathways (eg, the Commonwealth CareLinks and Victorian Primary Care Partnership8). Supporting tools initiated by governments include service directories, consumer assessment and service coordination templates, referral mechanisms (both printed and Web-based) and consumer/carer charters.

The full potential of information technology has not yet been harnessed. For example, including a "carer status" field in patient records would prompt early identification of care responsibilities. Software could also alert GPs to provide information or follow-up, and could even include (or electronically link to) carer fact sheets and resources, such as those produced by the national carer organisation Carers Australia.

Even GPs committed to working with carers can face considerable barriers to implementing a proactive approach. The patient may not agree to the carer participating in the consultation, or the carer may be reluctant to discuss how he or she is managing, especially if the patient is present or the carer perceives the GP to be too "busy" or very medically focused.4,5,7,10 Either the patient or the carer may be reluctant to accept external assistance.5,6,10 The carer may forgo his or her own health checks or treatment plan because of the pressures of caregiving.2 Finally, in addition to lack of training, information and resources,5-7,11 GPs have to cope with increasing demands, time constraints and inadequate remuneration,5,7,9-11 problems that are often difficult to overcome.

The Enhanced Primary Care (EPC) Medicare Benefits Schedule items provide an opportunity to focus on carers and partly address the issue of remuneration for GPs.12 With the patient's consent, carers can be formally included in care planning and case-conferencing activities. This enables GPs and other healthcare workers to hear carers' views on how well they and their patients are managing at home. GPs and carers can then jointly consider options for coordinated support. Where carer wellbeing is an issue, staff of regional carer respite services (or other workers assisting the carer) can usefully be involved.6 Health assessments, another EPC item, should also include screening for carer issues.

However, GPs may still need to grapple with the thorny issues of consent, conflict and reluctance — interpersonal issues arising in the relationships between patients and carers and between patients/carers and their doctor.

Much of the responsibility for monitoring patient records and maintaining information resources can be delegated to the practice manager or an allied health professional. For example, practice nurses have effectively undertaken health assessments13 and are well positioned to provide carer health education, service referral and coordination. A counsellor or carer-support worker attached to a general practice can assist with identifying carer needs and making referrals, as well as helping the carer to develop skills and to work through emotional or relationship issues.6

The Better Outcomes in Mental Health Initiative14 is relevant to assisting carers who are experiencing severe stress, anxiety or depression. The initiative provides incentive payments for mental health needs assessment, planning and review activities to doctors who register interest with their local Division of General Practice and receive training. We believe that including educational material on carer mental health issues in training packages would enhance this initiative.

Given the absence of clear strategies and leadership on this issue over the past four years, the development of clinical practice guidelines and policy positions by governments and peak practitioner bodies is needed. The evolving Commonwealth-funded Primary Health Care Research Evaluation and Development Strategy15 provides an ideal opportunity to prioritise collaborative research in this area. The demonstration of the benefits to carers, those they care for, and the community generally, of an overtly aware and interventionist clinical approach is well overdue.