Volume 175 Issue 2

GP Corporatisation The why and the wherefore Barry R Catchlove MJA 2001; 175: 68-70 For editorial comment, see Van Der Weyden Abstract - What is corporatisation? - Why corporatisation now? - What do GPs think? - What are the consequences of corporatisation? - Alternative models? - References - Authors' Details - - More articles on General practice and primary care Abstract Through their clearly defined gatekeeper role, GPs have considerable market power to influence the flow of revenue associated with referrals and prescriptions. For this reason, and because the whole healthcare industry is going through a transition from a cottage industry to a more commercially sophisticated structure, corporatisation of general practice is on the increase. If properly and ethically run, corporatised general practices can provide high-quality, efficient primary care. There are four far-reaching, potential consequences of general practice corporatisation — an increase in healthcare spending; limitation of GPs' choice of practice environment; difficulty justifying GPs' legitimate fee increases; and de-skilling of GPs. Over the past two years there has been a huge upsurge in corporatisation of Australian general practice. It began in Perth, Western Australia, and is now spreading across metropolitan Australia. An estimated 2500 GPs (about 10% of those in practice) now work in practices owned by large corporations.1 What is corporatisation? Definitions of corporatisation vary, but all include the concept of changing the traditional ownership and practice structures to improve the profitability of general practice.2 In terms of what is happening now in Australian general practice, a working definition would comprise: A third party — doctor(s) or non-doctor(s) — acquires an interest in one or more general practices. Whatever the equity arrangements, GPs enter into a contract whereby they assign a proportion of their gross income in return for management of their practice, provision of support services, and a goodwill payment. The third party then gains access to the flow-on services of the practice (eg, pathology and radiology) and may benefit financially from the GPs' referrals. The practices are merged into a single medical centre, which is generally separately owned by the same third party. In Australia, corporatisation of medical services is not a new phenomenon. Large corporations own many private hospitals and most pathology and radiology services, and third parties, be they entrepreneurial doctors or people from outside healthcare, have been acquiring general practices for years. The current situation is therefore not unique, because: GPs are being offered previously unheard of goodwill payments. The rate of practice acquisitions has increased dramatically. Ownership of diagnostic services by corporate entities is now common. Specialists are now joining these corporate medical centres. The new corporate owners are often listed companies and may have "big name" investors, adding further to the high profile of the new structure. There is a clear intention to capitalise on the GPs' market power (in addition to achieving some economies of scale). Why corporatisation now? The interesting question is not why corporatisation is happening, but why it is happening now. After a review of corporatisation commissioned by the Commonwealth Department of Health and Aged Care in 2000,3 the answer to this question is still not entirely clear. As is often the case in the commercial world, there is no obvious trigger. It is worth recalling the 18th-century economist Adam Smith's famous remark about the "invisible hand of the market".4 However, two important and relevant issues, external to the medical profession, shed some light on the upsurge of corporatisation. Firstly, GPs have considerable market power, which, in this context, means the ability, through a clearly defined gatekeeper role, to influence the flow of revenue associated with referrals, prescriptions and suchlike. We know that for each dollar of Medicare revenue earned by a GP, another $1.60 is generated directly in diagnostic and specialist consultations. Based on the flow-on effects of one GP's initial decisions, it is estimated that 20 GPs' decisions could be responsible, directly and indirectly, for as much as $50 million of healthcare expenditure per annum.3 In the past, the cottage industry nature of general practice, with an average of fewer than two doctors per practice, made it difficult to exploit collective market power. Secondly, the whole healthcare industry is going through a transition from a cottage industry to a more commercially sophisticated structure. Ironically, this started in the public sector — public hospitals were grouped into areas, regions and networks. In the 1990s, it spread to the private sector with the involvement of large third party commercial organisations, the rationalisation of pathology then radiology services, and it is now having an impact on general practice. Even the charity hospitals have been forced into merging and forming corporatised structures. This process appears inevitable and unstoppable. What do GPs think? Despite widespread concerns being voiced within the profession and in the media, GPs currently involved in corporate-run practices are not complaining. At this early stage of corporatisation most appear happy. There is no evidence to suggest they are being pressured into overservicing or into directing patients to particular diagnostic services or specialists. GPs who previously owned practices have received a relatively large and unexpected goodwill payment. They are probably earning about the same as they did before corporatisation, but they have been freed from the administrative tasks of running their practice. In a business sense many would agree that GPs from inefficient and grossly undercapitalised practices needed to be dragged into the 21st century. If properly and ethically run, corporatised general practices can provide high quality, efficient primary care. On a more sober note, it must also be remembered that all these new entrants into corporatised general practice have only existed for a short time and therefore can only be judged on short-term performances. What are the consequences of corporatisation? At this stage, the real issues of corporatisation are not about the compromise of clinical autonomy (although there is no denying this could be a problem but not necessarily associated with corporatisation alone). I believe that, apart from some of the more obvious issues such as ownership of records and freedom to refer, there are four far-reaching, albeit subtle, consequences of corporatisation. Although corporatisation will get the blame, these four are in reality consequences of the inevitable changes associated with transforming healthcare from a cottage industry to a more rational, market-driven service sector. These include limitation of choice, increases in healthcare spending, difficulty justifying legitimate fee increases, and de-skilling of GPs. Limitation of choice There is a real risk that the corporate model will become so dominant that future GPs will have little choice about the sort of practice in which they wish to work. This is already happening to some extent in metropolitan Perth.5 For general practice to attract doctors, it needs to offer a range of alternative models from solo general practice right through to large corporate medical centres. The only way is to ensure viable alternatives offering equivalent benefits and advantages. Crucial to this is the creation of saleable goodwill. Increases in healthcare spending The real profitability in owning a general practice is not in the direct revenue, but in the "downstream" revenue, which is the product of GPs' gatekeeper role. The corporate groups believe that access is the key (not coercion). If a pathology collection centre or pharmacy is placed within the confines of a medical centre, then about 95% of the referrals can be assumed without any need to adopt overt pressure. The corporate practice benefits from ownership of diagnostic services, but, even if it doesn't (as is often the case for pharmacy and allied health services), it benefits from being able to demand premium rentals for floor space. Specialists who take consulting space in these medical centres may also be prepared to pay excessive rentals to gain access to a large number of GPs. The real concern is the subtle impact on referral rates, diagnostic and pharmaceutical expenditure. Take as a hypothetical example the presence of a full time dermatologist in a large medical centre (please forgive me for selecting a dermatologist, it could equally apply to other specialists). It is inevitable that many of the patients previously managed, and managed quite effectively, by GPs will now be referred. Again, access is key, with higher patient expectations, convenience, and perhaps even medicolegal concerns about not referring when the service is so readily available. Given the cost differential between GP and specialist consultations, both the referral rate and the cost per patient attendance will inevitably rise. If this situation is extrapolated to other possible diagnostic and specialist referrals, there is a potential for considerable increases in Medicare and Pharmaceutical Benefits Scheme spending. How will governments react to this? Very simply, they will encourage the already developing move to fund-holding, coordinated care, fund pooling — call it what you will. All these mean a move away from fee-for-service and towards managed-care models and the associated transfer of risk. If GPs control the budget, will government allow corporatised practices to share the savings, and if GPs have a vested interest in reducing referral rates what will be the impact on the downstream revenue? Could this undermine the viability of the corporate players already paying high prices for general practice acquisitions? Difficulty justifying legitimate fee increases Being owned by high profile, often publicly listed, successful corporate entities might decrease the ability of the medical profession to argue a case for legitimate fee increases. Imagine the situation — two large publicly listed corporate practices, perhaps partly owned by high profile entrepreneurs, announce record profits at the same time that representatives of general practice organisations are meeting with government to discuss increases in the fee schedule. De-skilling of GPs If every conceivable diagnostic test, specialist and ancillary service is available on site, and this results in increased referrals, then there is a likelihood that GPs will become nothing more than a postbox, and there is a real potential for de-skilling of GPs. A GP's clinical judgement will become largely unnecessary. Taking this situation to extremes, someone might eventually ask whether the GP's gatekeeper role is working and mightn't a much cheaper nurse practitioner fill the same role? Alternative models? What corporatisation has demonstrated is that there are more efficient ways to deliver primary healthcare. For those who acknowledge this, the challenge is to provide alternative models, drawing on the lessons of corporatisation. The KPMG report to the Commonwealth Department of Health and Aged Care asked some searching questions about the use of GP market power. Properly managed and with due regard to ethics, this market power can be used to improve care, reduce costs and improve the quality of practice. If GPs are prepared to responsibly manage their gatekeeper role, which often requires increased time and effort, they should be rewarded. GPs should be best suited to manage and control their market power. However, it is something of a truism that if you have such power and do not use it or control it then someone else will. Corporatisation in general practice is merely one aspect of the movement of health services from the cottage industry to a more rational and rationalised model. To argue a return to the good old days and the status quo would be attempting to do what King Canute proved was impossible — holding back the tide. References Corporate structure [news review]. Australian Doctor 2001; 27 April: 29-31. Australian Medical Association. General practice corporatisation. AMA scoping paper. Canberra: AMA, November 2000. Commonwealth Department of Health and Aged Care. Corporatisation of general practice: scoping paper. KPMG Consulting, May 2000. Smith A. An inquiry into the nature and causes of the wealth of nations. London: W Strahan, T Cadell, 1776. Kron J. Risky business. Australian Doctor 2001; 16 Feb; 45. Authors' Detials Barry R Catchlove, MB BS, FRACP, Director. No reprints will be available from the author. Correspondence: Dr Barry R Catchlove, Director, Padua Consulting Pty Ltd, Health Services Consulting, 11 Burton Street, Mosman, NSW 2088. bcatchloATbigpond.net.au Make a comment

Barry R Catchlove

GP Corporatisation The divisional alternative Arn Sprogis MJA 2001; 175: 70-72 Abstract - Divisions as corporations - "Divisional corporate model" versus "for-profit corporate model" - Conclusions - References - Authors' details - - More articles on General practice and primary care Abstract GPs working together in groups, with a corporate body providing the organisational framework, is an inevitable outcome of healthcare system changes. Divisions of General Practice — regional corporations owned and operated solely by local GPs — should be seen as the logical alternative to the non-regional, for-profit, often publicly listed corporations. The divisional model combines economies of scale and organisation with clinical and practice autonomy and a regional focus, as well as an emphasis on patient values, quality of care, and equity of access. The Hunter Urban Division of General Practice is exploring the possibility of a Division-based general practice cooperative. In the Australian healthcare system, particularly in general practice, major structural change occurs about every 30 years.1 The move to corporatisation, which has been evolving slowly for the past 10 years or so, is clearly the next major structural change. GPs, as the entry point into the healthcare system, are the most important part of the change process — their corporatisation completes the process for medical practitioners. General practice responses to these changes will determine the final form and outcome for the health system as a whole and, most importantly, the type and availability of care that patients can expect in the future. GPs working together in large groups, with a corporate body providing the organisational framework, is an inevitable outcome of healthcare system changes2 and part of an international trend.3 The factors influencing these changes include: A shift away from hospital-based to community-based care; Increased use of health teams in the community (eg, as part of the Enhanced Primary Care package); Greater use of drug treatments; An emphasis on population-based activity (eg, General Practice Immunisation Incentives scheme);1,4 Increased accountability for outcomes; Efficiencies resulting from improved management techniques; and Renewed interest by government and non-government groups in integrating health funding.2 In Australia, an additional factor has been pressure on the financial viability of general practice, particularly in capital cities. Divisions as corporations Most GPs have participated in a form of corporatisation since 1 August 1992, when the Commonwealth Government funded the pilot group of 10 Divisions of General Practice. Over the next two years, more than 120 Divisions were formed covering most of Australia.1 These regionally based, GP-owned, patient- and community-focused, not-for-profit corporate entities afforded an opportunity to further develop general practice corporate activity, but this opportunity was not grasped by governments for the next seven years. Indeed, this policy vacuum allowed the emergence of "for-profit" general practice corporate groups and should be seen as a public health policy failure. "Divisional corporate model" versus "for-profit corporate model" If a corporate approach to general practice is accepted as inevitable, then Divisions of General Practice — regional corporations owned and operated solely by local GPs — should be seen as the logical alternative to the non-regional, for-profit, often publicly listed corporations. If general practice is a private-sector activity, why not allow market forces to play their role and let the most efficient corporations, regardless of structure and ownership, dominate the field? The real question is: Can the for-profit, publicly listed corporations meet the challenges integral to the ethical and value systems of the GP-patient relationship? Overall, I do not believe that the for-profit corporation model sits well with individual and community-based healthcare or that the conflict-of-interest issues can be satisfactorily overcome using this model. There are a number of clear advantages to patients, doctors and to the health system of a divisional corporate model approach. Ethical issues The basic tenet of the GP-patient relationship is that the GP has the patient's best interests in mind.5 Although all GPs experience ethical tensions, those working for publicly owned corporations (as opposed to a divisional corporate model) may not be able to reconcile their own and their patients' values with the demands of the corporation's shareholders. The primary responsibility of corporations is to their shareholders. GPs may be induced to put corporate profits before the interests of their patients. Practice structure A clear distinction between a divisional model and a publicly owned corporate model is that the divisional model seeks to retain and build on the strengths of the current diverse practice structure, with its equally diverse operational types. It emphasises the autonomous operation of each practice, which makes its own business and clinical decisions within an overarching supportive divisional framework. A publicly owned corporation has to take control of individual practices and make them fit into the broader corporate strategy. Clinical and practice autonomy The ability of GPs to act independently for their patients' benefit must be preserved in corporatised general practice.6 A divisional model's overarching corporate goals and structures would respect, strengthen and reward individual practices. For a practice or GP to forgo any autonomy, there would have to be a clear benefit for both the GP and his or her patients. The divisional regional approach meets the needs of individual GP shareholders, both practice owners and employees. Regional focus and ownership GPs are part of the community in which they work, live and send their children to school. Publicly owned corporations, on the other hand, may not be based in the same region, or even the same country, as their corporate general practices. Few shareholders live in or have any commitment to the local region. Patients and communities already have strong feelings about the lack of regional responsibility of large corporate entities (eg, banks and oil companies). The divisional model enhances the capacity for population-based activity and increases the possibilities for enacting public policy. GPs involved in making decisions within the local divisional corporation are able to guarantee that the interests of their patients are also represented at the regional level. Quality of care The capacity to provide quality care, a key element of professional general practice,4 should not differ according to ownership structure. Several of the Divisions are already leaders in the field of "evidence-based and best practice" treatment,7 but publicly owned, general practice corporations have yet to demonstrate their capacity or their commitment in this crucial area. Equity and access This is a point of major differentiation between the divisional corporate model and the publicly owned corporate model. The Divisions are committed to offering participation within their structure to all GPs, both owners and employees (as well as to all their patients), regardless of their potential for profit generation. In the publicly owned corporate model, GPs' acceptance may be the result of a selection process, with preference given to those most likely to generate a profit. Finance and third-party relationships Improvements in GPs' remuneration and practice finances will require more than increases in individual consultation fees. It will require resource-sharing arrangements with third-party providers (eg, preferred-provider arrangements with pathology laboratories) and government agencies (eg, general practice fundholding). These arrangements must be mutually beneficial (for reasons of efficiency, competition, or public policy). GPs and patients potentially benefit from third-party partnerships as a means of redistributing healthcare resources5 (eg, pharmaceutical companies supporting evidence-based drug use by GPs). The ethical challenge presented by funding relationships between general practice corporations and third parties (eg, pathology services, pharmaceutical companies, and government departments) has yet to be resolved.5,8 The financial relationships of public corporations are often based on "commercial in confidence" and secrecy, whereas those of the divisional model are transparent and open to public scrutiny. Conclusions A Division-based, general practice regional cooperative model appears to be the only corporate option combining the benefits of economies of scale and organisation, but at the same time maintaining congruence with regional patient and community interests, general practice autonomy and public policy imperatives. The experience of the Hunter Urban Division of General Practice in exploring a regional general practice cooperative is shown in the Box. References Commonwealth Department of Health and Aged Care. General practice in Australia: 2000, Canberra: Office of the Medical Advisor, DHAC, 2000. Commonwealth Department of Health and Aged Care. The Australian Coordinated Care Trials: Interim Technical National Evaluation Report, 1999. Canberra, DHAC, 1999. King J, Wilson M. General practice: building on quality literature review. Melbourne: Monash Institute of Public Health, 2001. Commonwealth Department of Health and Family Services. General Practice: changing the future through partnerships 1998. Report of the General Practice Strategy Review Group. Canberra: DHAC, 1998. Smith D. Reconciling the ethics of general practitioners and third party incentives, part 2, 2001. <http://www.hudgp.org.au/ethics/thirdparty/part2.asp> (accessed June 2001). RACGP corporatisation taskforce. Heywood L (chair). <http://www.racgp.org.au/taskforces/corporatisation/keyissues.htm> (accessed June 2001). Magarey A, Rogers W, Sibthorpe B, et al. Dynamic divisions: a report of the 1997-98 Annual Survey of Divisions. Adelaide: National Information Service, Department of General Practice, Flinders Medical Centre, 1999. Marshall D. Beneficial ownership of Approved Pathology Authorities and medical centres. HIC Forum 2001; Vol 12. Authors' details Hunter Urban Division of General Practice, Newcastle, NSW. Arn Sprogis, FRACGP, DRCOG, DipClinEpi, Executive Director. Reprints will not be available from the author. Correspondence: Dr A Sprogis, Executive Director, Hunter Urban Division of General Practice, PO Box 572, Newcastle, NSW 2300. drarnAThudgp.org.au Make a comment Divisional corporate model in action The Hunter Urban Division of General Practice (HUDGP) is exploring the possibility of a Division-based general practice cooperative. The HUDGP encompasses the regions of Newcastle, Lake Macquarie, Maitland and Port Stephens in New South Wales. The region contains urban, industrial and rural sectors within the Lower Hunter Valley with a population of about 400 000 people. The HUDGP represents 380 GPs in 160 practices. HUDGP currently has several successful divisional projects, including: A general practice cooperative after-hours service in the Maitland district (population 70 000). The service, which operates from Maitland Hospital, is staffed by the 70% of local GPs who are members. The service is funded by a divisional grant. There is a plan to form five similar services to cover the entire Lower Hunter region. Support services for Division members, including information technology, immunisation, accreditation and professional development. A nursing service, providing a contract nurse on request. Since late 2000, the HUDGP has been consulting with its members about forming general practice cooperatives as an alternative to joining "publicly listed" corporations. The cooperative model is strongly preferred. Key characteristics would include: Coverage of the Hunter Urban region only. The HUDGP providing practice management support and expanding on current services (above). Individual GPs retaining clinical and practice autonomy. Support for all practice sizes and styles (rather than selecting GPs who fit the corporate model). Issues such as structure and funding are currently being explored. Back to text

Arn Sprogis

GP Corporatisation The ethics of doctors and big business Paul D Fitzgerald MJA 2001; 175: 73-75 Abstract - Doctors and corporate influences - Doctors as agents for corporations - The informed consumer - Professional response - Government response - Conclusions - References - Authors' details - - More articles on Administration and health services Abstract Ethically conducted medical treatment puts the healthcare needs of patients first, ahead of profit, but corporations may pressure GPs to act as their agents instead of the patient's agent. The medical profession requires an industrial code outlining the specific conditions needed to maintain high standards of medical practice. Health professional organisations also need a code of conduct. Recent legislation should limit the influence of corporations on doctors: non-medical directors of medical corporations can now be fined or disqualified if they are party to professional misconduct by medical practitioners, and GPs can be prosecuted for offering or accepting pecuniary benefits for referrals. Doctors need to act now to implement systems which protect the public interest and professional standards before the influence of corporatisation becomes pervasive, and leads to increased legislation and regulation of medical practice. Doctors are sometimes criticised for glorifying the past and fearing the future, but there are lessons to be learnt from the past. Structures and patterns of medical practice have evolved over many years, and have contributed to the relative success of the Australian healthcare system. Medical ethics evolved to protect the doctor-patient relationship,1 and to support the role of GPs as brokers or advocates for their patients within the health system. These ethical principles ensure that GPs are free to act in their patients' best interests and to contract with their patients without hindrance from third parties. Understanding the key role played by GPs, corporations, insurers, drug companies and governments are all keen to influence them, and thus exert influence in the health market. But this influence may not be in the public interest. As an example, directors of corporations have an ethical responsibility to protect the interests of their shareholders. Successful businesses focus on their customers, but only within the limits of their obligations to deliver security and profit to their shareholders. Ethically conducted medical treatment, on the other hand, puts the healthcare needs of patients ahead of profit. Doctors and corporate influences In New South Wales there have been several examples of doctors being induced to put profit first and disregard medical ethics, to their patients' detriment. In the report of its inquiry into impotency treatment services,2 the New South Wales Health Care Complaints Commission (HCCC) described how a corporation recruited men by advertising or telephone recruitment, and used doctors to sell them untested, unapproved penile injections, at a price mark-up of up to 10-fold. The inquiry revealed inadequate sterilisation and preparation standards, increased risk of phimosis and Peyronie's disease, and inadequate diagnostic and treatment procedures. Doctors received a share of the profits through direct payment and subsidisation of their overhead expenses. According to the HCCC report, some of the doctors involved developed a form of ethical dissociation, justifying the clearly inadequate treatment and fraudulent prescribing as giving the patients what they wanted. The report of a second inquiry by the HCCC, the Cosmetic Surgery Report,3 raised concerns about non-medical referral agents, such as beauty therapists, referring patients to doctors in return for payment of secret commissions. Cosmetic clinic staff received financial incentives for recruiting patients for therapeutic procedures and then subjecting them to sales tactics to purchase additional cosmetic treatments. The report also raised concerns about consumer helplines (conducted by product manufacturers) referring people to doctors, and doctors arranging loans for patients to pay for their cosmetic surgery. Perhaps the most fertile field for corporations has been the operation of medical centres, with vertically integrated pathology and radiology services, as well as specialists and pharmacies. A recent report of the Professional Services Review Committee4 noted that some doctors in corporatised practices had been pressured to see as many patients as possible, and there were suspicions that pathology tests and diagnostic imaging requests were encouraged. Doctors as agents for corporations Common themes with these examples include: Corporations directly target healthcare consumers, promising to provide a product or service. In some cases, the service is as much a consumer product as a health service. The consumer is directed by the corporation to consult the corporation's doctor. This is a key point for the corporation, as consumers generally assume that doctors operate to a professional standard and in the best interests of patients. The doctor appears to be an agent of the patient, but is in fact an agent of the corporation. The consumer is misled and, on the recommendation of the doctor, agrees to purchase the product or to bill the health insurer for the service. The corporation rewards the doctor, either directly or indirectly, for inducing the consumer to purchase the additional goods or services. Thus, the corporation induces the doctor to act not as the patient's agent, but as the agent of the corporation. This is an abrogation of the doctor's ethical responsibilities and a breach of the doctor-patient relationship. When costs are met by a third party, such as an insurer, the problem may be aggravated by an absence of a price signal. Corporations may see this as successful marketing, but the profession and the public would be alarmed that doctors could be induced to betray their patients' trust. The informed consumer In an ideal market, this situation would not arise. The consumer would be sufficiently informed to choose from a range of options and purchase the most suitable product, based on performance, durability and price. However, the health system is not ideal. It is very complex, and there is considerable discrepancy between the information available to the consumer and that available to the provider. In fact, most people don't become sufficiently informed to make logical choices until well after they have become a consumer of health services. The key to protecting consumers is deciding who the informed consumer really is. If we accept that the definition extends to a patient operating with the advice and assistance of his or her GP — a "single economic unit interacting with the rest of the health care system"5 — then it becomes imperative to ensure that GPs are always free to put their patients' interest first. Professional response The way doctors practise is largely determined by their training and ongoing professional education. Undergraduate, postgraduate and continuing education programs must emphasise ethics and professional standards. In contrast to nurses, doctors in Australia have traditionally separated their professional and industrial representation. There is a need to review this arrangement, and to link professional standards with industrial representation. The medical profession requires an industrial code that also outlines the specific conditions needed to maintain high standards of medical practice. With linked industrial and professional representation, nurses have maintained and furthered their professional standards in work environments not dissimilar to those of GPs in corporations. An industrial code for doctors could provide both a framework for corporations employing or contracting doctors, as well as guidelines for industrial, civil or disciplinary action. However, in view of recent conflict between the medical profession and the Australian Competition and Consumer Commission over industrial representation of doctors who are contractors rather than employees, industrial representation of GPs in corporatised practice could be a daunting prospect. For GPs working in small practices, there is a real need for practice management expertise to be more accessible, and for there to be a range of models to meet this need — practice management consultancies, virtual or actual practice amalgamations and Division-based projects.6 With greater management assistance, GPs may be able to make their practices more viable so that corporatisation becomes a choice rather than a necessity. A code of conduct is also required at the level of health professional organisations. These organisations are vulnerable to influence from both government and corporations, especially where funding grants are concerned. There is also the possibility of undue influence when an office bearer or senior employee of a health professional organisation is recruited from a corporate or government post, or takes such a position soon after leaving the organisation. A code of conduct for senior employees and office bearers of professional associations and colleges could assist in maintaining their independence as defenders of professional standards. A more detailed description of the impact of corporatisation of medical practice and professional responses is available on the Australian Medical Association website.7 Government response The Medical Practice Amendment Act 2000 (NSW) contains two initiatives which could change the environment for corporatised medicine, and assist GPs in both corporatised practices and managed-care environments. These initiatives have come as a result of lobbying from doctors and consumers, and an analysis of the inquiries by the HCCC mentioned above. Non-medical directors of corporations providing medical services can now be fined or disqualified if they are party to unsatisfactory professional conduct or professional misconduct by medical practitioners. These provisions also extend to provision of excessive or unnecessary medical services. The NSW Minister for Health has the power to make regulations to determine evidence of this sort of conduct. This power may be a world first, and deserves professional support. Although medical boards and tribunals are mostly able to deal with the outer limits of professional misconduct, this legislation could be used as a precedent for civil action by doctors, medical defence organisations, and for industrial initiatives. Another provision prohibits doctors offering or accepting pecuniary benefits for patient referrals, and includes corporations providing medical services, as well as their directors and managers. If these provisions are enforced, they could have widespread implications for the operation and profitability of vertically integrated healthcare corporations in New South Wales. Other States are considering or enacting similar legislation. At a national level, there should also be consideration of parallel legislation covering eligibility for Medicare rebates under the Health Insurance Act 1973 (Cwlth). As a result of consumer and government concern about the effects of "for profit" corporations on delivery of healthcare in the United States, federal laws have been enacted governing financial relationships between doctors and healthcare corporations.8 The attempts of legislators to direct and codify medical practice through the Stark laws has significantly disrupted normal patterns of medical practice. Conclusions In Australia, successive governments at State and federal level have encouraged the transition of the Australian health system to a "free market" model, with little understanding of the way the health market operates, or of the role GPs play in protecting the public interest. Listed public companies have come to dominate some market segments, such as private pathology and imaging services, and now seek a significant segment of the general practice market. Corporations are set to become dominant players in all segments of the health system, including provision of specialist, private hospital and health insurance services. Doctors have a narrow window of opportunity before the influence of corporations becomes pervasive. They must act now to put in place systems which protect the public interest and professional standards, or suffer the consequences of stockmarket control, and increased regulation of medical practice. References Australian Medical Association. Code of ethics. Canberra: AMA, 1996. 1998 Report of the Ministerial Committee of Inquiry into Impotency Treatment Services in New South Wales. Sydney: New South Wales Health Care Complaints Commission, 1998. <http://www.hccc.nsw.gov.au/hccc/pdf/impotency_report.pdf> (accessed June 2001). Cosmetic Surgery Report. Report to the New South Wales Minister for Health. Sydney: NSW Health Care Complaints Commission, October 1999. Professional Services Review Annual Report 2000. Director's report. Canberra: Ausinfo, 2000: 8,9. Risk and return in doctors Inc [editorial]. Australian Financial Review 2000; 30 May: 20. Sprogis A. GP corporatisation of general practice: the divisional alternative. Med J Aust 2001; 175: 70-72. Australian Medical Association website. General practice. <www.ama.com.au/ index.html> (accessed June 2001). Ethics in Patient Referrals Act of 1989, HR 939 SC, The Stark II Law (42 USC 1395nn), HCFA releases phase 1 of the Stark II regulations, Latham & Watkins Health Care Practice Group Bulletin No 139 Feb 1: 2001 <http://lawcommerce.com> (accessed June 2001). Authors' details North Sydney, NSW. Paul D Fitzgerald, FRACGP, FAFPHM, FAIM, General Practitioner, Public Health Physician. Reprints will not be available from the author. Correspondence: Dr Paul D Fitzgerald, Suite 303, 83 Mount Street, North Sydney, NSW 2060. docfitzATihug.com.au Make a comment

Paul D Fitzgerald

GP Corporatisation The consumer perspective Kathy Mott MJA 2001; 175: 75-76 Abstract - Consumers' expectations of corporatisation - Consumers' concerns and ideals - References - Authors' details - - More articles on General practice and primary care Abstract As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs. Consumers will gain if corporatisation means doctors are freed from administrative tasks and can spend more time with their patients, but pressure to increase profits may compromise the GP-patient relationship. A broad range of services "under the one roof" offers convenience and ease of access for consumers, particularly families and older people. All types of practices should listen to consumer concerns, and strive to meet their expectations of quality, accessible healthcare and good doctor-patient communication. Do most people know who "owns" their local medical clinic? More importantly, do most people care? The answer to the first question is likely to be "no", but the answer to the second question is not as obvious or clear-cut. As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs and contributes to their recovery or their ongoing health. Consumers have a wide range of criteria for choosing a doctor or medical centre, or deciding whether their needs will be met by using one practice or a range of practices. In the absence of financial or physical barriers, their choice of a particular healthcare provider is based on a complex set of criteria, including proximity, availability, sex of the doctor, special skills or interests of the doctor, and perceptions of the doctor's personality and ability.1 With the rise of corporatisation, consumers may now want to include in these criteria who owns the service, and what effect ownership may have on the services they receive. The potential for conflict of interest is very high in any private health service, but it would be surprising if many consumers took this into account in their healthcare decisions. In a corporatised practice, owners and shareholders may exert pressure, albeit subtle, for referral and use of certain services in which they have financial interests. Currently, consumers have no way of knowing whether they are being overserviced or whether the doctor is getting a "kick-back". Transparency about ownership of "downstream" services, both for corporatised practices and owner-operator practices, would assist consumers to make informed choices. People with chronic health conditions or with multiple healthcare needs are often restricted in their choices by their income and their reliance on public hospitals and bulk-billing GPs. Leaving these issues aside, what might be the arguments for taking ownership into account when choosing a general practice? Consumers' expectations of corporatisation Corporatised general practice might allow doctors to spend more time with their patients Corporations owning general practices maintain that, with modern administrative and management systems, they can run the practices more efficiently, leaving doctors to concentrate on patients and medical issues. This is certainly an attractive argument. As consumers, we like doctors to give us their undivided attention, to focus on our needs, to provide us with the most up-to-date and relevant treatments, and to supply all necessary information. If corporatised general practice enables doctors to spend more time with consumers and thus better meet their needs, then that would be an advantage. However, the doctor may be under pressure to produce the income to support the corporation (and its inevitable middle management infrastructure) by seeing more patients more quickly. Anything that reduces time spent with consumers would be a negative effect of corporatisation. There have been frequent references in the media over the past 10 years to the "high-turnover, three-minute medicine, no appointments necessary, 24-hour, corporate-style clinics" with lots of doctors, all "bulk-billing" their fees. Is this the future with corporatised medicine? Corporatised general practice might offer a broader range of services Corporate groups with associated allied health, pathology and radiology services offer convenience and ease of access for consumers, including extended hours of opening. The "one-stop shop", with all the services under one roof, has great appeal, and may save people time and trouble. This may be a boon, especially for those with multiple medical conditions, older people, and families with young children. There is some debate about whether this model is demand driven (consumers asked for it), or supply driven (the corporation simply provides these services). Private medical services are profit-making concerns, and it is common knowledge that downstream services such as pathology and radiology generate large profits.2 Large multifaceted medical corporations might provide subtle incentives to encourage doctors to order tests. Consumers are in no position to challenge these referrals. Corporatised general practice might raise the quality of services offered The Standards for General Practice of the Royal Australian College of General Practitioners (RACGP)3 place great emphasis on the structures and environment of general practices. A corporation with a commitment to quality management systems may be able to improve general practice performance against these reference standards. Consumers would then benefit from their clinic being part of a large professionally run organisation. But most of the practices that so far have met the RACGP standards and received accreditation have been GP-owned (Mr David Wright, General Manager, Australian General Practice Accreditation Ltd, personal communication). They have been able to meet the standards without help from corporatisation. They have established sound systems of record keeping, they appropriately sterilise their equipment, and they maintain privacy of patient information. They can effectively establish recall systems and have accessible and properly equipped facilities. Corporatised practice might affect the doctor-patient relationship A good relationship with their doctor is an important issue for most consumers. They want to trust their doctor and anything that causes them to doubt their doctor's integrity would be a serious issue. Doctors in corporatised practices may be under subtle pressures to put corporate and profit issues before the best interests of their patients. Consumers' concerns and ideals On balance, corporatisation of general practice may offer some advantages, but equally there could be some serious drawbacks. The general practice issues that most concern consumers include: Short, rushed consultations with no time to deal with complex issues; Poor communication of information generally; Limited integration with allied health services; and Lack of acknowledgement and acceptance of alternative therapies. Consumers need to be reassured that the rise of corporatised general practice in Australia does not perpetuate problems of poor-quality healthcare (or, indeed, lower standards further), and especially that it does not compromise the doctor-patient relationship. Some advocates of corporatisation claim that all stakeholders will benefit. At the same time, there are concerns about the profit motive and the demands of investors, not consumers, being given priority. A set of standards for the business management of general practices should be drawn up. Consumers have high, but not unrealistic, ideals for their interaction with GPs. Consumers think that GPs should: Improve their communication with patients; Provide appropriate, timely and quality healthcare; Make general practice services more accessible; Provide, or facilitate access to, a wider range of services to meet consumers' needs; Take a more active role in linking consumers to health and support services; Communicate with consumer organisations; and Make better use of information technology to meet consumers' needs.4 All types of general practices, whether corporatised or not, should strive to meet these expectations. References Consumers' Health Forum of Australia and the Commonwealth Department of Human Services and Health. Integrating consumer views about quality in general practice. Canberra: AGPS, 1996. Moynihan R. Too much medicine? Sydney: ABC Books, 1999: 80-102. Royal Australian College of General Practitioners. Standards for general practices. 2nd edition. Melbourne: RACGP, 2000. Consumers' Health Forum of Australia. Consumer expectations of general practice in Australia, 1999. <http://www.chf.org.au/issues/gp_expectations.html> (accessed June 2001). Authors' details Consumer Perspectives, Adelaide, SA. Kathy Mott, BA, Director. Reprints: Ms Kathy Mott, Consumer Perspectives, 329 Brighton Road, North Brighton, SA 5048. kmottATbigpond.com Make a comment

Kathy Mott

GP Health Australian general practitioners: desperately seeking satisfaction Is the satisfied GP an oxymoron? MJA 2001; 175: 85-86 General practice can be soul-destroying. Over half the general practitioners in a 1996 Australian survey considered abandoning general practice because of occupational stress, and 13% had symptoms of severe psychiatric disturbance.1 In an article by McGlone and Chenoweth in this issue of the Journal, nearly one in four Victorian GPs reported dissatisfaction with their work, while a similar proportion reported a neutral position.2 On the international scene, GPs are no happier. Those in the United Kingdom shut their surgeries in May this year to protest against working conditions imposed by the government.3 In the same month, GPs in the Netherlands went on strike for three days over insufficient government funding of general practice.4 A British survey showed that more than one in four GPs had borderline or likely depression and were more likely than hospital consultants to exhibit suicidal thinking.5 Why should this be? Contrary to popular belief, it is not so much the clinical aspects of general practice that appear to be the main stressors (although some cases can exact their toll), but rather the interplay of organisational issues such as time pressures, phone interruptions, paperwork, fear of litigation, financial pressures, and low job control.1,2,6 Many doctors also appear to have personality traits (such as being highly self-critical) which predispose them to stress symptoms.7 Solutions Large-scale reform is clearly needed. Such reform should include greater consultation with GPs on issues impinging on their professional autonomy, from healthcare policy to workforce and training to remuneration. As the various general practice advocates play out their responses to the Relative Value Study8 or call for alternatives to fee-for-service, it is clear that greater financial remuneration is a major issue. Practical strategies to improve the plight of GPs also have to be implemented as early as possible in the GP lifecycle, from the stage of medical student, to vocational trainee, and to practising GP ( Box). Despite the policies and activities outlined in the Box, there is a dearth of research evaluating which strategies work to reduce GP stress. A search of the database listing projects funded by the General Practice Evaluation Program showed that only four out of 248 projects listed from 1990 to 2001 dealt with GPs' health, mainly concentrating on assessment of job stress and health needs (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication). How can individual GPs improve job satisfaction? By professional upskilling and practice management: Much has been written on how to address the most frequent job stressors, and evidence exists to support some strategies. For instance, as dissatisfied GPs identify having more "heartsink" patients, acquiring the skills to deal with "difficult" patients can be useful.13 Practising patient-centred care (which includes recognising when patients' psychosocial problems are relevant and dealing with them) is more satisfying, but also more stressful unless strategies such as longer patient booking intervals are employed.14 Hospital outpatient staff who participated in decision-making through more frequent staff meetings reported higher job satisfaction.15 Practice staff meetings may well benefit GPs, particularly in ironing out organisational problems and providing support. By upsizing: Many have looked to share the administrative, financial and clinical load by joining group practices or by corporatising. By downsizing: GPs working at least six sessions per week have been to shown to be more highly stressed,1 so part-time practice and job sharing may well be the solution for some. The anecdotal evidence is that this works particularly well for women, who are more likely to be juggling professional and personal roles. By sidestepping: Again, anecdotes abound on the success of combining clinical practice with other professional activities such as teaching, writing, and even medical editing (as one of us [M C] has done!). By self-nurturing: Self-care is vital given the inverse relationship between job satisfaction and job stressors,6 and the fact that problems with work and with close relationships are associated with poorer physical, psychological and social functioning.16 This includes healthy eating, exercise, adequate rest, spending time with family and friends, and pursuing non-medical interests. It includes acquiring a regular source of care (such as having a regular GP), and peer support (such as a support group). It may also include active stress management, and data from a systematic review suggest that relaxation and cognitive-behavioural techniques are the most effective at alleviating job stress.17 All GPs should also be aware of services such as the Doctors' Health Advisory Service. Yes, general practice can be soul-destroying. But there is also great privilege and satisfaction to be had in our partnerships with our patients. Changing the culture for GPs to progress beyond dissatisfaction or mere survival to greater job satisfaction is vital. There are signs that these changes are evolving in the policies and practices of professional institutions. However, strategies for change have to encompass grappling with our professional and personal lives. And remembering the ultimate words on keeping perspective in practice — no one ever died wishing they'd spent more time at the office. Mabel Chew Deputy Editor Alison Williams Kincaid-Smith Editorial Fellow The Medical Journal of Australia Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. McGlone SJ, Chenoweth IG. Job demands and control as predictors of job satisfaction in general practice. Med J Aust 2001; 175: 88-91. Kmietowicz Z. GPs shut surgeries in protest at government targets. BMJ 2001; 322: 1082. bmj.com news roundup. Dutch GPs take three day strike action. BMJ 2001; 322: 1142. Caplan RP. Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ 1994; 309: 1261-1263. Cooper CL, Rout U, Faragher B. Mental health, job satisfaction, and job stress among general practitioners. BMJ 1989; 298: 366-370. Firth-Cozens J. Predicting stress in general practitioners: 10 year follow up postal survey. BMJ 1997; 315: 34-35. Australian Department of Health and Aged Care, and the Australian Medical Association. Relative value study. <http://www.health.gov.au/rvs> (accessed 28 June 2001). AMA Position Statement. Health of medical practitioners. <http://domino.ama.com.au/AMAWeb/Position.nsf/> (accessed 28 June 2001). NSW Doctors' Mental Health Program. Doctors' Mental Health Policy. <http://www.dmh.org.au/dmh/policy.html> (accessed June 2001). Doctors' Health Advisory Service website <http://www.dmh.org.au/dhas/inter-state%20addresses.htm> (accessed 27 June 2001). RACGP. Content for teaching and learning. <http://www.racgp.org.au/training/curriculum/content.pdf> (accessed 28 June 2001). Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract 1995; 45: 293-296. Howie JG, Hopton JL, et al. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract 1992; 42: 181-185. Jackson SE. Participating in decision making as a strategy for reducing job-related strain. J Appl Psychol 1983; 68: 3-19. Stansfeld SA, Bosma H, Hemingway H, Marmot MG. Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehouse II study. Psychosom Med 1998; 60: 247-55. Sims J. The evaluation of stress management strategies in general practice: an evidence-led approach. Br J Gen Pract 1997; 47: 577-582. Make a comment Current policies and practices supporting self-care for general practitioners Professional bodies such as the Australian Medical Association9 and the Doctors' Mental Health Working Group in New South Wales10 have outlined position statements and strategies which emphasise the need for educational, training and clinical institutions to promote mental health and self-care as essential to students and doctors; to promote early recognition of mental health problems, early intervention, and confidential treatment and rehabilitation where needed; and to provide working conditions more conducive to wellbeing, such as reasonable working hours, adequate leave, flexible career pathways and mentor programs. The Doctors' Health Advisory Service in each State and Territory (offering independent, confidential medical help to doctors and medical students during personal crises) is advertised in the medical media, and contact details are available on the Internet.11 University medical curricula include core objectives throughout the course which deal with the stresses of clinical practice and self-care as students and doctors; these themes are also the focus of specific teaching and learning activities. The Royal Australian College of General Practitioners (RACGP) Training Program — until recently, the body responsible for vocational training in general practice — has a curriculum which has a self-care component12 and, in NSW, conducts interactive sessions on self-care in two compulsory workshops for registrars (Dr Hilton Koppe, Medical Educator, RACGP Training Program, personal communication). The RACGP Quality Assurance and Clinical Education (QA & CE) Program for GPs records 40 activities (out of a total 6 948) related to GP self-care for the 1999 to 2001 triennium (Maree Morgan, Activities Coordinator, QA & CE Program, RACGP, personal communication). The National Information Service Activities of Divisions Database (for which 66 out of 123 Divisions of General Practice submitted plans from July 2000 to June 2001) shows that 42 Divisions reported having activities or programs which specifically addressed GP wellbeing (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication). Back to text

GP in Action Reactive or preventive: the role of general practice in achieving a healthier Australia The time has come to expand the role of general practitioners in population health MJA 2001; 175: 92-93 General practitioners in Australia provide much preventive care, including screening for diseases and risk factors, vaccination and preventing complications of chronic disease. Profession leaders, supported by Commonwealth, State and Territory governments, now advocate extending the patient-centred clinical role of the general practitioner (GP) to include more emphasis on the health of practice populations and local communities1 (Box 1). This extended role builds on the value and trust that the community has in GPs and the access that GPs have to most of the population.3,4 The aim is not only to tilt the balance between the curative and preventive roles of the GP, but also to develop a more systematic approach to prevention for the whole practice population. This shift presents a particular challenge in Australia, where patients are not formally linked to practices, as they are in the United Kingdom and New Zealand.5General practice provides numerous opportunities for preventive care. The Royal Australian College of General Practitioners (RACGP) recently published the extensively revised fifth edition of its Guide to preventive care in general practice,6 also known as "The Red Book". This is a synthesis of evidence-based guidelines from Australian and other sources and provides recommendations for everyday use in general practice (Box 2). By implementing these recommendations, GPs can make a real contribution to reducing the burden of disease in Australia. At a recent national symposium, the Joint Advisory Group on General Practitioners and Population Health (JAG) developed a consensus statement on the role of GPs in population health, along with a strategic framework to take this forward. JAG comprises representatives from the General Practice Partnership Advisory Council (which includes representatives from general practice, consumer and Indigenous health groups and the Federal Government) and the National Public Health Partnership (which includes government health officials from each State and Territory). One of the new strategies is SNAP, which aims to enhance the screening, assessment and management of behavioural risk factors through brief interventions on Smoking, Nutrition, Alcohol and Physical activity. These interventions are made during consultations, and are supported by systems in the practice and the local Division of General Practice, which also provides education, information systems, community education and referral mechanisms.9 However, there are many practical barriers to the shift towards preventive healthcare. GPs are weary of change and wary of new responsibilities. Many lack time, and some lack the specific skills required, such as techniques to change patient behaviour. The current Medical Benefits Schedule rewards mainly episodic care, rather than preventive care for groups of patients in a practice. The Enhanced Primary Care Medicare items and Practice Incentives Program payments need to be extended to support preventive activity not only in specific groups such as older people, but across practice populations. Preventive care requires approaches that are evidence-based, systematic and sustainable. Specific requirements include:10 individuals in the practice dedicated to helping coordinate and organise preventive activities (eg, practice nurses); health promotion resources, such as patient questionnaires, posters, pamphlets, audiotapes, videotapes and library resources developed specifically for general practice; structured records and health summaries, as well as patient-held records; electronic reminder and decision-support systems; patient education resources for use in consultations; and liaison with community and population health organisations and services (eg, local health promotion units, support and healthy lifestyle groups), and systems for referring patients. Efforts to build GPs' capacity to use information technology (IT) are well under way in Australia. Electronic support tools for clinical decision-making, recall and reminder systems and patient education and information are essential for effective preventive care. However, existing software for GPs is not well suited to these tasks, nor to data collection and analysis at practice or Division levels. A standardised architecture for IT systems must be developed. It is also difficult to ensure access to preventive care for all patients. Some groups have increased risk of diseases because of social or other factors (eg, their place of residence, economic resources, skills and lifestyles).7 Paradoxically, while poorer health means disadvantaged groups are major users of general practice, they are also the lowest users of preventive care services.11 Any strategies to develop the role of GPs in population health must address this "inverse care law". Disadvantaged groups may need to be specifically targeted in general practice, and the financial barriers addressed, especially in rural areas where fewer GPs bulk bill. The Divisions of General Practice need to support GPs' adopting a more systematic approach to preventive care within their practices. The Divisions also have a key role, along with universities and vocational training consortia, including the professional Colleges, in helping GPs understand and practise evidence-based preventive healthcare, organise preventive interventions, and reach and care for disadvantaged groups. Nevertheless, GPs cannot achieve this alone. Most are fully occupied with their current roles and have limited capacity to take on new ones. There is a need to expand and train the workforce within general practice to include people other than GPs, such as practice nurses. Evidence from the UK suggests that these nurses can play a key role in developing preventive activity within general practice.12 This strategy needs to be evaluated urgently in Australia. Stronger links to other services are also needed at a Division level. There is a need to develop programs shared between Divisions of General Practice, population and community health and Indigenous health services to identify and address the needs of local communities and groups for better preventive healthcare.13 It is important to recognise that there is already a cadre of trained public health specialists who can provide support and leadership in this area. This is not a short-term task. It will take a decade for this role to be fully developed. However, it is time to start. Mark F Harris Chair, Joint Advisory Group on General Practice and Population Health Professor of General Practice, University of New South Wales, Sydney, NSW Paul J T Mercer Chair, Preventive and Community Medicine Committee Royal Australian College of General Practitioners, Melbourne, VIC General practice: changing the future through partnerships. Report of the General Practice Strategy Review Group. Canberra: Commonwealth of Australia, 1998. The role of general practice in population health. A joint consensus statement of the General Practice Partnership Advisory Council and the National Public Health Partnership Group. Draft June 2001. Canberra: Commonwealth Department of Health and Aged Care, 2001. Joint Advisory Group on General Practice and Population Health: Consultation Paper. Canberra: Commonwealth of Australia, Apr 2000. General practice in Australia: 1996. Canberra: Commonwealth Department of Health and Family Services, 1998: 201-233. Harris MF, Frith JF. Continuity of care: in search of the Holy Grail of general practice. Med J Aust 1996; 164: 456-457. Royal Australian College of General Practitioners. Guide to preventive activity in general practice. 5th ed. Melbourne: RACGP, Jun 2001. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Heath and Welfare, 1999. Mathers CD, Vos ET, Stevensen CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Department of Health and Aged Care. SNAP: Integrated approach to risk factor management in general practice. Canberra: Department of Health and Aged Care, Mar 2001. Royal Australian College of General Practitioners. Putting prevention into practice: a guide for the implementation of prevention in the general practice setting. Melbourne, RACGP, 1998. National Health Strategy. Enough to make you sick. How income and environment affect health. National Health Strategy Research Paper No 1. Melbourne: Commonwealth Department of Health and Family Services, 1992. Jolly K, Bradley F, Sharp S, et al. Randomised controlled trial of follow-up care in general practice of patients with myocardial infarction and angina pectoris: final results of the SHIP trial. BMJ 1998; 318: 706-711. Royal Australian College of General Practitioners. Collaboration in primary health care: case studies of divisions of general practice and community health services working together. Melbourne: RACGP, 1999. Make a comment 1: Definition of population health The General Practice Partnership Advisory Council and National Public Health Partnership Group define population health in the context of general practice as2 The prevention of illness, injury and disability, reduction in the burden of illness and rehabilitation of those with a chronic disease. This recognises the social, cultural and political determinants of health. This is achieved through the organised and systematic responses to improve, protect and restore the health of populations and individuals. This includes both opportunistic and planned interventions in the general practice setting. Back to text 2: Some recommendations on preventive activities for general practice by the Royal Australian College of General Practitioners6 Condition (% of total DALYs) Recommendation Tobacco (12.1% male, 6.8% female) Smoking status should be assessed for every patient over the age of 10 years. Patients who smoke, regardless of the amount, should be offered brief advice to stop smoking. Physical activity (6.0% male, 7.5% female) All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all, days of the week. High blood pressure (5.1% male, 5.8% female) Blood pressure should be measured in all adults from age 18 at least every 2 years. Alcohol (6.6% male, 3.1% female) All patients should be asked about the quantity and frequency of alcohol intake from age 14 years. Brief interventions to reduce alcohol consumption should be offered to all patients with potentially hazardous levels of drinking. Obesity (4.3% male and 4.3% female) Body mass index and adult abdominal circumference should be measured every 2 years for patients who appear overweight or underweight. All patients identified with higher risk should be advised to modify energy intake and physical activity habits. High blood cholesterol (3.2% male, 1.9% female) "At risk" patients should be screened between the ages of 20 and 75 years as part of absolute cardiovascular-disease risk assessment. Screening of healthy people without risk factors is recommended every five years starting at age 45. Diabetes (4.7% male, 4.1% female) All patients should be screened every 3 years from age 65. Screening should commence at age 50 in those with other risk factors, and at age 35 in Indigenous Australians and people from the Pacific Islands, Indian subcontinent or China. Breast cancer (6.9% female) Screening every two years by mammogram is recommended for women aged 50-69 years. Clinical breast examination is not recommended as a routine screening test. Bowel cancer (4.4% male, 3.8% female) Screening by faecal occult blood testing is recommended every 2 years for all people aged over 50 years. However, opportunistic case finding only is recommended for general practice until current trials to determine the optimal type of tests are completed. Colonoscopy is recommended every 1-2 years from age 25 years for those at high risk. DALYs = age-standardised disability-adjusted life-years in 1996.7,8 Back to text