The increasing prevalence of chronic conditions requires general practitioners to implement structured care with their patients. This care is often multidisciplinary. Our experience through two coordinated care trials has shown that GPs often have a network of private allied health care providers, but have limited knowledge of the complete range of services available in the community and how to gain access to these services.

Dr Beres Wenck (GP), Ms Alison Nason (Practice Nurse Milton Clinic) and Ms Jenny Bostock (Community Health Nurse)

We suggest that there are three key elements essential for GPs to improve multidisciplinary care systems in their practice:

• Find the GP champion in your practice with an interest in chronic disease management who can encourage behaviour change. Appoint a member of the practice staff to be the link with your local community nursing agency. These organisations have an enormous knowledge of the breadth and depth of patient services available, and can help you find appropriate services for your patients. Invite community health nurses to your practice, or meet with them at their centre. Learn to use their expertise by forming and building a relationship. The collaboration has to be two-way, with community nurses equally committed to liaison. Such a change is likely to not only benefit GPs, but also enhance community nursing awareness of local general practice issues.

• Develop team-building and educational strategies for GPs and practice staff, as this will maximise team efficiency and productivity and boost staff morale. Have a meeting with all practice staff (not just the GPs), and encourage all present to contribute. This will result in knowledgeable and resourceful practice staff who will complement patient management. Use the chronic disease modules developed by Brisbane North Division of General Practice1 to set up a structured clinical education program. This can be based either within a single small group practice or within a locality, to provide the opportunity for GPs, staff, and, when appropriate, allied health care providers, to discuss evidence-based medicine and practice-based issues relating to chronic disease management.1

• Involve your practice staff in care planning to help improve patient understanding and care. Medicare Benefits Schedule (MBS) item numbers allow access to five allied health private services a year for those with complex, chronic conditions.2 The new MBS Chronic Disease Management item numbers replacing previous Enhanced Primary Care items include a Management Plan and Team Care component, and were developed from our Team Care Health II learnings. They allow practice staff to assist GPs in planning care, and will facilitate service coordination, especially if the practice has established links with community agencies.

These elements need to be put in place at the practice level, but Divisions of General Practice should develop collaborative relationships with community stakeholders for linkages at the local level. Furthermore, to recognise the time-consuming nature of implementing the necessary changes within general practices, there should be appropriate innovative financial incentives for GPs and practices to make this approach a viable option.

With the increasing prevalence of chronic conditions, we need to move our focus from a reactive health care model to a proactive service delivery model. Get the incentives right, get the support right, and you might be surprised at the difference you make.