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Providing healthcare for people with chronic illness: the views of Australian GPs

John Oldroyd, Judith Proudfoot, Fernando A Infante, Gawaine Powell Davies, Mark F Harris, Tanya Bubner, Chris Holton and Justin J Beilby
Med J Aust 2003; 179 (1): 30-33. || doi: 10.5694/j.1326-5377.2003.tb05414.x
Published online: 7 July 2003

Abstract

Objectives: To explore general practitioners' views on chronic-disease care: the difficulties and rewards, the needs of patients, the impact of government incentive payments, and the changes needed to improve chronic-disease management.

Design: Qualitative study, involving semi-structured questions administered to 10 focus groups of GPs, conducted from April to October 2002.

Participants and setting: 54 GPs from both urban and rural practices in New South Wales and South Australia.

Results: Consistent themes emerged about the complex nature of chronic-disease management, the tension between patients' and GPs' goals for care, the time-consuming aspects of care (exacerbated by federal government requirements), and the conflicting pressures that prevent GPs engaging in structured multidisciplinary care (ie, team-based care involving systems for patient monitoring, recall, and care planning).

Conclusions: Structured multidisciplinary care for people with chronic conditions can be difficult to provide. Barriers include the lack of fit between systems oriented towards acute care and the requirements of chronic-disease care, and between bureaucratic, inflexible structures and the complex, dynamic nature of GP–patient relationships. These problems are exacerbated by administrative pressures associated with federal government initiatives to improve chronic-illness management. Changes are needed in both policies and attitudes to enable GPs to move from episodic care to providing structured long-term care as part of a multidisciplinary team.

Chronic diseases such as diabetes, cardiovascular disease, asthma, cancer and depression are imposing an increasing healthcare burden in Australia,1 particularly in general practice, where they account for a high proportion of consultations. There is increasing evidence that care of patients with chronic illness requires a structured multidisciplinary approach across services, involving systems for patient recall, auditing and monitoring, as well as educating and supporting patients in the self-managment of their condition.2

However, not all general practitioners in Australia use structured multidisciplinary care, and an estimated 50% of patients with chronic diseases do not receive best practice management.3-5 To help general practices set up systems for effective chronic-disease care, the Commonwealth Department of Health and Ageing has introduced several initiatives, such as the Enhanced Primary Care [EPC]6 package, the Practice Incentives Program [PIP]7 and Service Incentive Payments [SIP]8 for diabetes, asthma and mental disorders. However, the uptake of these initiatives has been variable.9 For example, GPs have made considerable use of the health-assessment and care-planning EPC items, but not of the case-conferencing items.10 There has also been a highly variable uptake of the diabetes SIP, which can be claimed when a 12-month cycle of evidence-based care has been completed.11

The views of Australian GPs about chronic-disease care and the reasons why they do or do not engage with the chronic-disease initiatives are not entirely clear.12 The aims of our study were to:

  • investigate how GPs conceptualise chronic-disease care and the barriers to providing effective management;

  • explore GPs' perceptions of what patients with chronic illnesses require of general practice;

  • investigate GPs' views about the federal government's chronic-disease initiatives; and

  • seek GPs' opinions on what organisational systems and structures would improve chronic-disease management.

Results

Fifty-four GPs participated, of which 39 (72%) were men. The mean age of participants was 49 years (range, 31–67 years), and the mean number of years' experience in general practice was 24 (range, 9–41 years). Practice sizes ranged from one to 24 GPs (37% of participants were solo practitioners). Further detail about the practices is given in the Box.

Themes arising in the focus groups fell into seven broad areas.

Discussion

The key finding emerging from our study is that GPs experience conflicting pressures and increasing demands (from patients and from the Department of Health and Ageing) as they attempt to provide better care for patients with chronic disease. Many of the difficulties can be traced to their attempts to carry out effective care in a predominantly encounter-based system oriented towards acute presentations. Highly structured systems imposed from above are not sufficiently flexible to fit the complex needs and variable nature of the relationship between GPs and their patients with chronic disease. A further layer of complexity is added by the interplay of clinical and customer-relations/business issues in chronic-disease management. These seemed to have an impact both on what GPs were prepared to do and (relatedly) what gave them satisfaction.

A secondary finding was that sustained high-quality chronic-disease management requires changes to practice infrastructure that are not always affordable or easily implemented. The complexity of government incentives (paradoxically introduced to improve care of patients with chronic conditions), the paperwork involved and the changes to criteria have acted as disincentives for many GPs. This theme in our focus groups has been corroborated by the recent Productivity Commission report, General practice administrative and compliance costs, which highlighted the extent of the burden in general practice.13 Since the release of the report, the Department of Health and Ageing has allocated $31.5 million to help doctors reduce "red tape" by increasing the use of electronic patient records and improving practice systems. Although research evidence has shown that better practice systems will go some way towards improving chronic-disease care,14 it remains to be seen whether this package will ease the administrative pressures associated with chronic-disease programs or change GPs' perceptions about the burden of chronic-disease care.

Our findings suggest that change is also required from within general practice. Overseas research shows that one of the critical factors for improving chronic-disease management is the effective use of non-GP care providers and patient-care teams.15,16 While the GPs in our study were open-minded about the role of practice nurses in educating patients, generating recalls and undertaking routine tests, they did not see nurses reducing the GPs' burden of chronic-disease care by taking over clinical duties traditionally performed by GPs. Similarly, GPs' perceptions of the role of practice managers in chronic-disease care was limited, in most cases, to help with paperwork: the potential for practice managers to establish and run systems for patient recall, auditing and monitoring was not being recognised. The difficulties associated with implementing the EPC case-conference item have also acted as a barrier. Thus, in comparison with the United Kingdom and the United States, multidisciplinary teamwork within Australian practices appears to be underdeveloped. The relative weight of logistic versus attitudinal barriers to multidisciplinary care has yet to be ascertained.

Our study was limited by the convenience sampling method used and by the small size and perhaps unrepresentative composition of the sample (our GPs were somewhat older and more experienced than average). Nevertheless, our findings shed light on GPs' attitudes to chronic-disease management and the barriers to implementing structured multidisciplinary care. The policy implications of these findings are clear. Greater and more systematic involvement of GPs in care for patients with chronic disease is desirable and acceptable to most GPs, but it requires support that is more flexibly matched to the needs of patients and GPs. It will inevitably increase the workload of general practices at a time when many rural and urban areas face workforce shortages. The extra burden could be offset by simplifying the way programs such as the PIP are administered, providing additional funding for longer consultations, supplying financial support and facilitation to extend the role of non-GP practice staff in chronic-disease management, and strengthening the links between practices and state-funded services.

  • John Oldroyd1
  • Judith Proudfoot2
  • Fernando A Infante3
  • Gawaine Powell Davies4
  • Mark F Harris5
  • Tanya Bubner6
  • Chris Holton7
  • Justin J Beilby8

  • 1 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW.
  • 2 Department of General Practice, University of Adelaide, Adelaide, SA.


Correspondence: 

Acknowledgements: 

We would like to thank the general practitioners who participated in our study and the Divisions of General Practice through which invitations to participate were issued. The study is part of a larger research program funded by the Commonwealth Department of Health and Ageing. The Department of Health and Ageing was not involved in the study design, data collection, analysis or interpretation, and had no influence on the writing and submission of this article.

Competing interests:

None identified.

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