A strong primary medical care system is essential to the equity, efficiency and effectiveness of the health system as a whole.
General practice in Australia faces significant challenges to its capacity to fulfil its role and function: in its financing, recognition, capacity to provide comprehensive care, and integration with the rest of the health system.
Addressing these challenges requires a better system of remuneration for quality in general practice care, strengthening of the role of the generalist within the health system, involvement of Divisions of General Practice in service development, and establishment of collaborative networks and integrated primary health care services.
In the financial year 2004–05, there were 90 million attendances with general practitioners billed to Medicare, and 90% of the Australian population visited a GP at least once in the year.1 Although direct costs of care in general practice averaged 5.5% of the $78.6 billion total health care expenditure (private and public), general practice has significant influence on total expenditure on pharmaceuticals (24%, or $10.9 billion), specialist care/procedures (10%, or $7.9 billion), and hospitalisation (29%, or $26.4 billion).2 The burden of chronic diseases and their risk factors is large and increasing, with an increasing proportion of the population having more than one chronic illness or risk factor for chronic illness.3 The scale of these emerging health problems cannot be managed effectively by specialist services working in isolation from generalist primary care services.4 Health systems that include strong primary medical care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes, including lower mortality.5-8 For this reason, every major reform of health systems in industrialised countries over the past 30 years has involved efforts to strengthen and integrate generalist primary medical care.9
Despite these international trends and increased recognition of the need for a well developed primary medical care system, there are risks to general practice. First among these is the reduced numbers of graduates choosing to go into general practice training and high levels of professional dissatisfaction among those in practice. The reasons for this are complex, and include the overall workforce shortage, the fragmentation and lack of coherence of vocational training programs, requirements for trainees to work in areas of workforce need, the changing lifestyle expectations of generation X and Y doctors, who want a better balance between work and family, and the low income of GPs relative to other specialties.10,11 Whatever the reasons, these trends threaten to further weaken GP morale and the capacity of general practice to provide accessible, high quality primary medical care.
Thirty years ago, general practice was the main medical service provided in the Australian community. Today, more and more specialised services are based in, or at least delivered in, the community. Some of this specialisation has come from general practice itself — drug and alcohol, occupational health, sexual health, palliative care and aged care. Other community-based specialised services have come about as acute care services such as diabetes and mental health services have reached out into the community to prevent hospitalisation or provide alternatives to hospital outpatient services. These represent opportunities for working together and for GPs to expand their skills, but have also blurred the boundaries between generalist and specialist.
Central to the rationale for maintaining a strong role for general practice in the health care system is a clear articulation of its purpose and role. General practice provides first level primary medical care for most of the population. Its principal roles are to prevent illness, identify risk, offer early intervention, provide care for episodic illness and for chronic disease, and diagnose, refer and coordinate care for patients with acute and serious illness.12 This care is patient centred13 and should be:14
accessible, so that patients are able to use it in proportion to their need;15
comprehensive enough to meet all the common needs in a population or community;16
continuous, so that patients can receive consistent care and develop a relationship with their GP;17 and
coordinated, so that patients’ needs and concerns are not lost as they move between other health care services and providers.7
There are four key challenges to these roles and functions of general practice in Australia (Box).
Although the workload has increased since 1996 (as evidenced by the number of GPs per head of population), GP incomes have declined, especially relative to specialist incomes.18 Patient co-payments, although still low by international standards, have begun to increase and to affect access to general practice care by disadvantaged groups, especially in remote areas.19
There is an under-valuing of the generalist skills required to assess a broad range of health problems and manage them in a patient-centred way.20 The erosion of support for the generalist role is due, at least in part, to a failure of education, as well as the seemingly inexorable drive to greater specialisation within health care. This has accelerated the drift towards specialties and semi-specialised areas of general practice, despite the evidence of increased costs and decreased coordination.21
The workforce crisis has affected both availability and the duration of consultations required to deliver quality care.22,23 Although multidisciplinary care is essential to the comprehensive prevention and management of chronic conditions, incentives for practices to employ nurses and refer to allied health services have not fully overcome the financial and organisational barriers facing practices. State governments have increasingly focused the efforts of community and allied health services on post-hospital care, reducing the opportunities for teamwork with general practice in the care of patients who have not yet been hospitalised.
The role of general practice in providing continuity across episodes of specialist, semi-specialist or hospital care is not always accepted. The complexity of care has placed a great strain on communication between general practice and other services, much of which was poorly functioning to begin with. This is especially apparent in the frequent breakdown in continuity and coordination between GPs and hospital-based services.24
These challenges are complex and interact with each other. The response of general practice has been constrained by a variety of factors, including the fragmentation of general practice organisation itself.
Over the past decade, following the GP Strategy Review,25 the Australian Government has made a series of modifications to general practice Medicare items, including support for practice nursing in areas of workforce need. Reimbursements for aspects of quality of care, especially for patients with chronic disease, have also been introduced incrementally. However, this process may be close to its limit, as each new incentive adds to the overall complexity and “red tape”. Although it has had its critics, the new UK Contract for GPs services has provided both a boost to GP incomes and a more integrated approach to funding quality performance, with practices scored across targets for 10 chronic diseases, five organisational areas, measures of the patient experience (including access), and special service provision.26
Exposure to general practice in the prevocational years is about to be introduced and may contribute to greater awareness of the generalist role. However, more explicit education on the unique role and skills required in generalist primary medical care is needed, together with strategies to build the intellectual basis for general practice through investment in general practice research.27 There is a place for more GP involvement in specialist and semi-specialist activities. However, instead of having specialist standards and priorities imposed on general practice, we need a better understanding of how generalists and specialists can complement each other in teams.28
In a number of other countries, general practice has become a purchaser or commissioner of services.29 This allows general practice to take a more direct role in negotiating the provision of allied health or secondary services, thus strengthening the position of general practice. This is not feasible in Australia in the absence of patient registration and effective integration between Commonwealth- and state government-funded health services. However, some Divisions of General Practice have become involved in providing or brokering public and private allied health services in the prevention and management of chronic disease, and this appears to be successful in terms of improving both access and coordination.30,31
Although there is increasing recognition in government of the need for greater integration between general practice and other health services, it has been unclear who should take the lead in coordinating care, for example in the management of complex problems in early childhood or in older people. GPs themselves have been ambivalent, feeling that greater integration may threaten their autonomy.
One approach has been to set up structures for greater collaboration between public and private services and between Commonwealth- and state-funded services, such as the Primary Care Partnership models in Victoria.32 These have met with some success, especially in planning service development, bringing population and individual health care approaches together and facilitating multidisciplinary care. The collaborative nature of this approach means that there is less threat to the autonomy of the individual professions and services. However, the capacity of this approach to deal with issues of access or efficiency is correspondingly limited.
Another approach is to bring together general practice with other primary health providers in the one service. Aboriginal Community Controlled Health Services and Integrated Care or Community Health Centres, which bring together GPs, private and state-funded allied health and community health services, exemplify this approach. These facilitate multidisciplinary care and accountability for providing access to comprehensive care. They also provide a basis for greater integration between general practice and other primary health services.
Letters responding to an editorial in this journal 3 years ago declared that general practice was not in crisis.33 Acceptance of its role in the health system has increased. However, its capacity to fulfil these roles and functions is seriously challenged. In the absence of more radical change, there is a need for a better system of remuneration for quality in general practice care, strengthening of the role of the generalist within the health system, involvement of Divisions of General Practice in service development, and establishment of collaborative networks and integrated primary health care services. While the political process works to a 3–4-year cycle, strengthening general practice requires a longer term vision of primary health care as the key component of a more effective, efficient and equitable health system.
Some key challenges to Australian general practice, and possible responses
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