The future role and structure of Australian general practice remains uncertain, despite a decade of seemingly constant change following the release of the National Health Strategy papers.
Some of the suggested change strategies (such as rural Practice Incentive Payments and practice accreditation) have been implemented; others (such as general practitioner involvement with area health authorities in delivering national goals and targets for communities) still await attention.
An overarching vision for our health care system in 2020 and general practice’s role within it are still to be clearly enunciated.
Australia is at variance with other Western countries, such as the United Kingdom, Canada and New Zealand, which have spent significant time refocusing their health systems to deal with an ageing population with an increased burden of chronic disease.
Health bureaucrats and governments need to invest strategically in operational primary care now. This will require the active commitment of general practice’s national bodies to articulate and actively promote a shared vision for Australian general practice.
2020: Potential scenario 1
Dr Jones glanced quickly at her watch: 11:23 am — just time to file the final patient clinical note into Health e-Bank and settle into the conference room for the middle session of the working day — care planning. She activated the broadband “remote link”, opened e-Pharmacy, and checked that Sheila, the practice nurse, had loaded up all the clinical images and other information for the session (fundal photographs, pathology and scans, home blood pressure measurements). The practice team of dietician, lifestyle coach and psychologist would soon be arriving for the chronic disease management session. Today this would be followed by a “virtual” outpatients session for ear, nose and throat and neurology (she was the practice lead clinician for these, with advanced skill credentialling in both): 40 minutes for four patient ENT reviews and the same for neurology.
Early knock-off today — in time to collect the kids from school and finish with a dozen home e-consults and half a dozen quarterly e-self-management reviews for patients home-managing their blood pressures, blood sugars and renal function. Great things, e-consults — convenient for patients and accessible Australia-wide. The “City Docs go Bush” e-program was really booming. Sixty-two consults today, all up, and all patient concerns sorted out quickly and efficiently — a far cry from the long outpatient waits and delayed GP access of the past. Tomorrow would be more of an “acute” day — sharing a collaborative consulting roster with the triage nurse for patients requiring same-day assessment. General practice versatility — you had to love it!
Dr Smith swallowed two Prozac with his cold coffee and looked at the time: 4:30 pm, and the noise from the waiting room was rising to a crescendo. All this mumbo-jumbo about doctor oversupply — none of them seemed to be general practice-trained or interested. The practice seemed to be full of old, sick patients, many on lengthy queues for multiple hospital outpatient appointments. More drugs, more problems, more worry, little appreciable increase in quality of life. The system had become pretty scary — scary for patients, scary for GPs, and particularly scary for those working in secondary and tertiary care, where a lack of “generalist” skills meant that resources seemed to go nowhere.
“Time to get out”, thought Dr Smith, “before I become overwhelmed within a system that seems to have given up on me and my patients”. Maybe he could take one of those cushy “peer reviewer” revalidation positions or do a stint in cosmetic surgery. Seemed like clinical general practice these days had become too much work for too little personal return — time to move on and join the exodus out.
The future role and structure of Australian general practice remains uncertain, despite a decade of seemingly constant change following the release of the National Health Strategy papers between 1991 and 1993.1-5 Sadly, the issues raised in paper no. 3, The future of general practice,1 have changed little, with the exception of some progress in immunisation, remuneration for medical student teaching, and team care. Some of the suggested change strategies (such as rural Practice Incentive Payments and practice accreditation) have been implemented; others (opportunistic health promotion, general practitioner involvement with area health authorities in mutually delivering national goals and targets for communities, and patient linkage to general practice) still await attention 14 years on; and proposed strategies to reduce the GP workforce have been judged disastrous with the passage of time.
Organisations such as the Australian Divisions of General Practice and the Australian Health Care Reform Alliance have recently declared their respective visions for general practice,6,7 but an overarching vision for our health care system in 2020 and the role of general practice within it are still to be clearly enunciated. This is at variance with other Western countries, such as the United Kingdom, Canada and New Zealand, which have spent significant time refocusing their health systems to deal with an ageing population with an increased burden of chronic disease.8-10 The scenarios painted above are both real possibilities — one a huge winner for communities, governments and GPs; the second a progressive and expensive slide into a health system Armageddon. Importantly, the difference in outcome will be determined primarily by the ability of health bureaucrats and governments to invest strategically in operational primary care now. This will only be possible through the active commitment of general practice’s national bodies to articulate and actively promote a shared vision for Australian general practice.
The pressures felt by Australian general practice in 2006 are real and growing. The inadequate workforce, widely reported in recent years,11,12 continues to constrict the profession, with the real prospect of further reduction both in GP numbers and in their participation in practice for at least another 5 years. Joyce et al predicted that there would be no growth in GP numbers between 2001 and 2012, in stark contrast with an expected 25% increase in specialist numbers over the same period.13 While the increase in graduating doctors from 2010 onwards (as a result of the opening of new medical schools and introduction of full fee-paying students) will be welcome, there is little indication that many will enter general practice as we know it today.
With the increasing prevalence of comorbidity and a complex interplay between physical, social and environmental issues in health care, general practice is an increasingly difficult and time-consuming job. Current remuneration for the ongoing commitment required remains unattractive, particularly when compared with the ever-increasing number of more lucrative primary or secondary career options available in procedural, musculoskeletal, cosmetic, occupational or administrative medicine.
General practices are currently struggling to overlay new models of team care on an office infrastructure designed for GP consulting only. The required infrastructure investment in new rooms, communication resources, practice management and information technology costs is substantial, and is a key factor in decisions by smaller general practices on whether to adopt new initiatives.14
Imperfect linkage between primary and secondary/tertiary care in the public sector continues to be a source of inefficiency and of concern about quality, safety and the possibility of litigation. This disconnect is also a potent source of personal and professional frustration for both patients and GPs. Despite excellent work in improved information transfer shown by a number of Australian lead hospitals and Divisions of General Practice,15,16 the transfer of timely, relevant and legible clinical information between public hospitals and general practice remains unvalued by the health system — an unacceptable position for Australian consumers.
Current opportunities to improve health outcomes and delivery through primary care are numerous. With over 80% of Australians visiting GPs each year, the opportunities for population-wide health promotion and disease prevention via general practice are enormous.19 The recent commitment by the Council of Australian Governments in this regard is welcome. Structured chronic disease management in general practice is growing, supported by federal government initiatives such as the Australian Primary Care Collaboratives Program and the Lifescripts program.20,21 There are also ample opportunities to increase the Australian community’s capacity for disease self-management. Wagner22 has highlighted the importance of long-term patient commitment to successful chronic disease management, and programs teaching patients the skills needed to manage and live with their conditions have flourished in recent years.23 To stretch finite human resources in health most efficiently in face of an ever-growing need, we must learn to work more effectively with the millions of Australians who have chronic disorders. Primary care must play a key role in teaching, encouraging and supporting these initiatives. New approaches to consulting via the Internet and in-home monitoring could create new opportunities for patients to actively contribute to managing their own health care — to the mutual benefit of both the consumers and funders of health care.
Firstly, we need to make a decision. Do we want Australian general practice to be the glue that binds our highly technical and increasingly fragmented health care system together? How important is this central coordination role to a high quality, efficient, affordable health care system in the future? Is it a “must have” for the survival of a viable, accessible health care system in Australia?
If the answer is “yes”, we need to ask what support or change is needed. How does it fit with change, need and demand in other health and community care sectors? We need to rapidly identify people within (and outside) our health system who can help us answer these questions effectively and people who can translate the solutions into action — the sooner the better.
Secondly, we need to have a plan. Apart from the occasional individual organisational statement or vision, there is currently a policy vacuum in the area of integrated primary care strategy in Australia. This contrasts starkly with several other developed countries who have invested significant resources in the area. How can we safely navigate the difficult terrain of health care re-structure without a road map? Yet, if we don’t make a beginning — and soon — we risk moving towards an increasingly fragmented, remote and unsustainable health system. We need an articulated vision for primary care in 2020, endorsed, at a minimum, by the federal government and key national general practice groups. This should be supported by formulating clear objectives and strategies to address workforce problems, practice infrastructure, professional development and support (for both GPs and practice nurses), links and communication with the broader health system, realistic change management and efficient funding models. Funding models need to retain the traditional strengths of the present system while providing incentives for improved clinical performance, information transfer and skill acquisition and allowing funding packages for primary care of the kind that have been highly successful for communities overseas.24
Finally, let’s get the models right. In a country as geographically diverse as Australia, there can never be just one model. Many of the building blocks are in place. Practice nurse initiatives are thriving and expanding in many larger practices, and chronic disease management items funded under the Medicare Benefits Schedule have allowed experimentation with team models and new funding approaches to teamwork in primary care.
Innovative and relevant models in integrated care delivery between primary and secondary care are beginning to emerge, but will not grow unsupported. The University of Newcastle general practice model has developed a collaborative GP/nurse practice approach.25 The University of Queensland is moving towards an advanced primary care practice model that features skill-sharing, collaborative practice with secondary care, “virtual” consulting and support via Internet linkages.26
Such new models will require careful testing before implementation. As well as clinical and access measures, they will require careful assessment of the training, financial and business processes required. Additional nursing roles in triage and access support, lifestyle coaching, health promotion and patient education are well evaluated and successful overseas.27 A cornerstone of the new primary care will be communication by electronic means, which is broader than individual organisations and can be used to make care and information transfer safer, more efficient and easier for patients and clinicians.
Strategically investing in primary care poses many challenges — the challenge of shaping operator-driven small businesses into population-based care hubs; the challenge of designing expanded primary care models that reflect local health priorities, access and need; the challenge of managing change, people and resources and of promoting local leadership and vision; and the challenge of smoothly integrating service delivery between the primary, secondary and tertiary sectors.
We need a system map, a compass and a light to shed on the destination to be reached. Our objective should be to shape Australian general practice into one of the most robust primary care systems in the world — one that can support our communities and secondary and tertiary sectors to the optimum. We know we must do it to avoid the alternative calamity ahead. As a country, we have good people, the resources, and a number of the stepping stones along the way now in place. We just need the decision to set out, with the way clearly lit and all travellers committed and on the same road.
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- 2. National Health Strategy. In fair health? Equity and the health system. Background paper no. 3. Canberra: Department of Health, Housing and Community Services, 1991.
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- 11. Australian Medical Workforce Advisory Committee. The general practice workforce in Australia: supply and requirements to 2013. Sydney: AMWAC, 2005. Available at: http://www.health.nsw.gov.au/amwac/pdf/gp_2005.pdf (accessed Jun 2006).
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- 14. Carnell K. Primary health care — the health fix. National Press Club speech, 8 Mar 2006. Available at: http://www.malleedgp.com.au/file_upload/mdgp/ADGP/kcarnellnatpressclub08mar06.pdf (accessed Jun 2006).
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- 16. Ribbons R, Gardner B, Craig J. Implementing an integrated electronic discharge summaries solution to improve hospital communication with general practitioners. 11th National Health Informatics Conference; 2003 Aug 10–12; Sydney, Australia. Melbourne: Health Informatics Society of Australia, 2003.
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- 18. Starfield B. Equity in primary care. John Fry Fellowship lecture. London: Nuffield Trust, 2004.
- 19. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 6th ed. Melbourne: RACGP, 2005. Available at: http://www.racgp.org.au/downloads/pdf/2005Redbook_6th_ed.pdf (accessed Jun 2006).
- 20. Australian Government Department of Health and Ageing. Australian Primary Care Collaboratives Program (APCCP). Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pcd-programs-apccp-index.htm (accessed Jun 2006).
- 21. Australian Government Department of Health and Ageing. Lifestyle prescriptions. Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-lifescripts-index.htm (accessed Jun 2006).
- 22. Wagner EH. Meeting the needs of chronically ill people. BMJ 2001; 323: 945-946.
- 23. Royal Australian College of General Practitioners. Sharing healthcare guidelines — chronic condition self-management guideline for GPs. RACGP online, 2003. Available at: http://www.racgp.org.au/folder.asp?id=299 (accessed Jun 2006).
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