Volume 191 Issue 2

You can learn a lot about the future of Australian medicine by visiting the United States. Although I am home from my New York sabbatical, a short return trip allowed me to hear President Obama outline his plans for US health care reform to the American Medical Association. He noted that the American health care system is unfair, unaffordable and headed for bankruptcy. Paraphrasing loosely, it has features that are downright “un-American”. Strengths of the Australian system are the single payer (Medicare) for medical consultations and universal coverage. These will not happen in the US — Obama went out of his way to explain this. If they are not going to happen under Obama, it seems unlikely they will happen in the foreseeable future. The Obama plan does include what he calls the “public option”. This will make government-run health insurance — now available only to federal government employees — also available to the general population (or perhaps just the poor). Even this tentative move towards universal coverage has been heavily criticised by the Republican right as the first step on the pathway to the “evils” of socialised medicine. Unfortunately for the Obama plan, a significant number of Democratic senators don’t approve either. The worry is apparently that if the government starts supplying health insurance widely, it would compete with the private insurance industry. This would be un-American for many in the US, where the concept remains that the best health-funding system is a private one. The private system could be weakened by publicly funded insurance, as people moved from the private to the public not-for-profit sector. This assumes that the government insurance would be cheaper and would therefore entice people and employers away from private health insurance companies. In the end, the reasoning goes, the private system would collapse. Thus, the plethora of insurance plans will remain under the Obama plan and continue to bamboozle Americans. A new system making private insurance plans easier to compare is Obama’s weak solution to the current mess. Despite these negative features, there is much for us to learn from Obama’s eloquent speech and cleverly crafted US health care plan. He proposed to make it illegal for insurance companies to discriminate against people with pre-existing illness in obtaining medical insurance. This aligns with the Australian community rating-based system. He also proposed to reduce payments to hospitals with excessive early readmission rates. This would encourage hospitals to plan for patients’ mid- and long-term outcomes, rather than short-term state — something for Australia to think about. Obama pointed out that, in the US (and I suggest also in Australia), too much is spent on treatment that does not work. He particularly criticised incentives and other payments to doctors in the current US fee-for-service system, which he said encouraged doctors to do more tests and treatments than were medically needed. A collective cheer went up when he said that any health plan should allow doctors to be healers, rather than business people. However, the doctors in the audience went quiet when Obama, a lawyer, said he would not introduce a cap on malpractice claims, as he considered this would be unfair to patients. President Obama pointed out that there had been many unsuccessful attempts to modify the US health care system in the past. Whether or not the public insurance option is accepted, many elements of Obama’s plan will have direct relevance for Australia. He recommended that spending should increase on research to determine which medical care works best, pointing out that less than 50% of all cardiac care in the US is based on evidence. Large increases in funding for research on evidence-based clinical care and mechanisms for disseminating this information to doctors would have a substantial impact on American health care and would be (with perhaps some modification) directly relevant in Australia. In addition, the suggestion that mobile, accurate electronic records would be a goal of the plan may lead to technology that is directly applicable here. A major flaw in our health care system is the lack of ready access to accurate, verifiable medical data on sick patients. This is an even bigger problem in the more fragmented US system. If the problem is successfully addressed there with new technology, it could have major benefits for Australia. Although that part of the plan sounds good, it may contribute to the increasing potential for medical identity fraud, which I will discuss in my next postcard.

Jeffrey D Zajac MB BS, PhD, FRACP

Primary care is the foundation of our health care system, and successful health reform will depend on effective engagement with the primary care workforce Over the months that followed its election on 24 November 2007, the Rudd Labor Government proceeded to deliver on the series of health care commitments it had made during the election campaign.1 Australia saw the establishment of a National Health and Hospitals Reform Commission (NHHRC)2 and taskforces to develop a National Primary Health Care Strategy3 and a National Preventative Health Strategy,4 the latter of which will in the first instance focus on influencing major reductions in the diseases caused by obesity, tobacco and alcohol.5 The success of each of these reforms is dependent on effective engagement with Australian general practice. The final recommendations of each of these strategies will start to be rolled out over the coming months. This will be a time of critical challenge for primary care in Australia as the ideas contained in the strategies become framed as policies, and as incentives and penalties are developed to promote their implementation. This will also be a time of great opportunity for Australian general practice. Dr Christine Bennett, Chair of the NHHRC, has stated that We need to ‘rebalance’ health care to strengthen and integrate primary health care as the foundation of our healthcare system.6 These expected strategies are accompanied by other reforms initiated by government. In November 2008, the Council of Australian Governments (COAG) agreed to a package of health reforms,7 including the National Partnership Agreement on Preventive Health to improve the health of all Australians, which included the establishment of a national preventive health agency, and the National Partnership Agreement on Hospital and Health Workforce Reform, which provides the single largest investment in the health workforce ever made by Australian governments, with the Rudd Government investing $1.1 billion towards training more doctors, nurses and other health professionals.8 As part of the Australian Government’s commitment to reduce the 17-year life expectancy gap between Indigenous and non-Indigenous Australians, and in response to calls at the 2020 Summit,9 the government launched the National Indigenous Health Equality Council in July 2008,10,11 and in November 2008 announced a $1.6 billion investment by COAG in the Indigenous Health National Partnership, which expands primary health care and targeted prevention activities.12 Another example of the government’s renewed invigoration of primary care approaches to public health concerns was the establishment in March 2009 of a new ministerial advisory body on the national response to blood-borne viruses and sexually transmissible infections, including HIV/AIDS, viral hepatitis and chlamydia.13 These health reforms in Australia are taking place against an international backdrop of increased awareness about the need to strengthen primary health care in all nations, in order to address the current and looming health care challenges of the 21st century. In May 2008, the Director-General of the World Health Organization, Dr Margaret Chan, reaffirmed the WHO’s commitment to primary health care and described the consequences of “decades of failure to invest in fundamental health infrastructures, services and staff”.14 The 2008 WHO World Health Report was devoted to primary health care reform; titled Primary health care — now more than ever, it called on all nations to reinvigorate primary health care to better meet the health care needs of all people.15 At the same time, the Lancet issued a special edition on primary health care carrying the title Alma-Ata 30 years on. “Health for all need not be a dream buried in the past” and including a call for the integration of personal health care and public health at the level of the local community.16 The landmark report from the WHO Commission on Social Determinants of Health was released in August 2008; titled Closing the gap in a generation,17 the report makes a compelling call for close attention to health in all government policies. It describes how “gaps in health outcomes are ... indicators of policy failure” and champions “primary health care as a model for a health system that acts on the underlying social, economic and political causes of ill health”.14 There are important lessons in these reports for the health care reform process underway in Australia, including the need for equity in primary health care reforms18 and for the primary care sector to become part of the movement to change the wider physical, social and economic environments that support healthy behaviour, in addition to our work aimed at changing the behaviour of individuals.19 These moves towards major reform are now occurring against the background of the global financial crisis, as Australia and the rest of the world move into a period of economic recession. Global recession is likely to have serious effects on the health of the most disadvantaged, including the unemployed and the working poor.20 The recession is also expected to delay the implementation of many of the bold plans of the federal Labor Government. However, history has shown us that times of crisis also provide opportunities for remarkable, nation-changing leadership. The financial crisis, coupled with a federal government committed to equality of access and opportunity for all people in Australia, could see the stimulus for even more dramatic reforms than those expected in the forthcoming final reports of the NHHRC and the taskforces. The recession provides the opportunity to be creative at a time of limited resources and still achieve effective change. Achieving health care reform is more complex than just expending large amounts of cash to bring about desired changes. A recent example from the United Kingdom is the less than brilliant result of the allocation of billions of pounds to the Connecting for Health initiative of the National Health Service (NHS) which, while achieving success in some areas of e-health reform, has not yet delivered all that was promised.21 The Australian Government will face a serious challenge in integrating the recommendations of the NHHRC, the taskforces and its other health reform initiatives. It is hoped that serious consideration will be given to integration before the release of any final reports. The reform process will be hampered if mixed messages, especially concerning implementation of reforms, appear in the various government reports. There is also the risk that recommendations will be pitched at too high a level and will fail to generate real and practical reforms across the health system. One area of speculation has been around the future of Australia’s network of Divisions of General Practice and whether there will be a move towards establishing organisations that represent all of community-based primary health care,22 perhaps along the model of primary health organisations in New Zealand23 or primary care trusts in the UK, which “are now at the centre of the NHS and control 80% of the NHS budget”.24 Another serious consideration raised by the NHHRC is whether the federal government should assume “responsibility for all primary healthcare policy and funding”.6 Bringing together the cultures of the largely private primary care services funded by the federal government and the public, primary and community health services funded by the states and territories would be an extraordinary exercise in change management, but one which could achieve improvements in the coordination of primary care. Similarly, encouraging people with chronic disease to enrol with a single primary care team could enhance access to multidisciplinary preventive and chronic disease care services, and also increase the accountability of primary care organisations for the delivery of effective care to all members of their enrolled populations.22 The specific impact of individual reforms on health care provision to rural and remote communities will also need close attention, and may provide the opportunity for some exciting and inherently different models of care that could provide examples for other parts of the world. A core part of any successful reform is the need to invest in change. Rather than governments saying “This is the new policy and we are going to enact it”, our government would be wiser to empower the members of our community and this nation’s dedicated health professional workforce to see the possibility of how we might all do things differently. Every health professional in Australia has an understanding of what their job is and how to do it well. When someone says “We’re making some changes and this is now your new role”, there is an automatic negative reaction. If reform in primary care is going to be effective, widespread and sustained, our governments need to actively engage the entire primary care workforce, respect why people entered these jobs in the first place, and harness the manifold creative abilities of Australia’s skilled and highly educated health professionals. This involves having renewed respect for professional people and their values — health for all begins with respect for all. Reform will also bring with it ambiguities. Dealing with uncertainty and change is a core component of general practice; so is dealing with diversity and the need to be flexible. These are things we do well. They are fundamental to the nature of our clinical work. If the members of our general practice workforce can bring to the reform process the same resilience and creativity that they exhibit every day in clinical practice all around Australia, the nation could see lasting improvements in the quality, efficiency, equity and clinical outcomes of our primary care services. And that would not be a bad achievement.

Michael R Kidd MD, FRACGP

Complex educational, regulatory and financing rules and requirements influence the daily activities of Australian general practitioners, the scope of their professional practice and their remuneration. General practice, unlike medical specialties and subspecialties, is not built around a body of esoteric scientific knowledge and associated technical skills, and is particularly subject to influence through changes to the financing and regulatory structure under which it operates. This article discusses changes made to the general practice regulatory environment between 1989 and 2009. Two aspects of this sometimes contentious era are highlighted: the changing narratives used to describe general practice issues and the changing political interface between general practice and government over this period. Between 1989 and 2009, emphasis shifted from initiatives seeking to secure general practice as an autonomous professional discipline towards initiatives that sought to define and shape general practice within the broader health system. The political interface between general practice and the federal government evolved in parallel, from “corporatist” agreements initiated by national professional organisations, particularly the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP), to processes initiated and managed by government with involvement of a broad range of medical and other groups. Major changes 1989–2009Between 1989 and 2009, initiatives affecting GPs included: Compulsory postgraduate training (vocational registration) and continuing education, introduced to enhance the competence of individual practitioners. Practice assessment against practice standards, with funding under some federal government programs linked to this accreditation. New items introduced into the Medicare Benefits Schedule covering health checks for middle-aged people, people aged over 75 years and Indigenous people, as well as management plans for chronically ill patients. Local networks of GPs (Divisions of General Practice), created to integrate general practice into the wider health system. Extensive intervention in general practice workforce matters. For example, the federal government now determines the number of postgraduate GP training positions, and “area of need” provisions channel international medical graduates into rural and other less popular areas. Organised representation of rural doctors and incentive programs to support rural practice. The Vocational RegisterUntil 1989, a medical graduate who had completed a 1-year internship could enter unsupervised general practice. In March 1989, the RACGP and the federal Minister for Community Services and Health, Neal Blewett, announced details of their agreement to establish a vocational register linking payment of Medicare rebates with attainment of the College’s postgraduate fellowship. Services provided by registered GPs would attract higher Medicare rebates. Vocationally registered GPs, including experienced “grandfathered” GPs, would be required to undertake continuing education and agree to random practice audits of their medical records by a statutory independent peer review organisation. The College anticipated that annual incomes of vocationally registered GPs would increase by about $15 000.1 The Minister explained to parliament: The new GP arrangements are the most far reaching advances which have ever been achieved in general practice in this country ... [T]he Government expects general practitioners to be more willing to care for more complex conditions ... and to be more discriminating in their use of specialist referrals, prescribing and diagnostic tests.2 He further stated: [T]he Government and the RACGP are ... seeking ... changes in work practices which result in increased productivity in general practice.2 The agreement was controversial. The AMA, in opposing the initiative, denied claims that the AMA was “out of touch with the reality of government involvement in the provision of health care”, arguing that professional autonomy was at risk if parts of the health insurance arrangements were only open to doctors who agreed to participate in a government-approved scheme.3 Concern about the intrusiveness of an independent peer review organisation and lobbying by groups fearful of exclusion from the register led to review by a Senate committee. The committee concluded that “general practice and its practitioners have had to struggle for fair recognition ... [the legislation] gives recognition to general practice as a significant and separate area of medicine”. The Senate committee recommended that the proposal for an independent peer review organisation be rejected and that “the government provide the necessary legislative and other support for descriptor utilisation review to be carried out by the profession”.4 However, the Descriptor Utilisation Review Committee (DURC), established to develop this process and dominated by GP representatives, achieved nothing. The General Practice StrategyDebate about general practice moved to broader factors influencing the organisation and functioning of general practices. In January 1991, Tony Buhagiar, President of the RACGP, lamented that “general practice had drifted into a ‘morass’ and it urgently needed to be rescued ... the craft needed to have a unified direction”.5 In June of the same year, the Australian National University reported on a general practice financing think tank attended by government officials, academics and many “experienced and respected leaders of the general practice community”, which found “a surprising degree of consensus” that general practice is in serious difficulty ... [T]he system does not adequately reward general practitioners, does not encourage health promotion and prevention, does not promote continuity of care ... It promotes the “quick fix” mentality, entrepreneurial practice, excessive referral for laboratory and specialist opinion, and superficial responses to complicated problems.6 In July 1992, a document entitled The future of general practice: a strategy for the nineties and beyond7 — developed by the AMA, the RACGP and the federal government — was sent to all GPs detailing a package of proposals designed to “allow general practice to reassert its role as the cornerstone of Australia’s health care system”. Proposals included establishment of Divisions of General Practice under the control of GPs, an independent voluntary system of practice accreditation, and workforce initiatives to address the oversupply and maldistribution of GPs. Funding for these initiatives was provided in the 1992–93 federal budget.8 This was perhaps the high-water mark in the period 1989–2009 for general practice professional organisations seeking to shape the environment in which GPs work. The General Practice Strategy Review GroupIn 1997, Michael Wooldridge, the federal Minister for Health and Family Services from 1996 to 2001, established the General Practice Strategy Review Group to review the 1992 strategy. Members of the Group included two government officials (one of whom chaired the committee), a “consumer”, and two academic GPs. The other 11 members were practising GPs, some “independent” and others nominated by GP organisations.9 In its 333-page report, the Group noted “a widespread view that general practice still confronts serious problems. Innovative approaches are required if these problems are to be resolved”.9 The report predicted “during the next decade general practice will face an environment that is complex, fast-changing, uncertain, unfamiliar and competitive”,9 and identified low morale as a serious problem for GPs: “low morale derives from feelings about lack of direction, limited future options, low relative income, poor relationships with others and loss of control”.9 The report proposed “an ambitious and broad ranging program of activities which will ensure general practice reaches its full potential ... and consolidates its place at the centre of the health care system”.9 Recommendations of the report included: A listing of the core services that should be available through any general practice, including technical and medical services, with the view that provision of these core services might eventually become one of the requirements for accreditation as a general practice. Development and implementation over 5 years of a program to help general practices embrace microeconomic reform, including improved practice and workforce efficiencies, amalgamation of practices, and other models of cooperative working.9 These recommendations, which would have had a major impact on Australian general practice, were not implemented. The General Practice Partnership Advisory Council, which, like the 1989 DURC, was dominated by general practice representatives, was established to advise on implementation. Like the DURC, this produced few outcomes and was eventually disbanded. 2003–2007: an “Indian summer” for general practice?During Tony Abbott’s time as Minister for Health and Ageing, from 2003 to 2007, bold reform proposals were not pursued. He argued: The Howard Government has always been more interested in making a practical difference than in flaunting its “reform” credentials ... Constantly emphasising the need for reform implies that the existing system is much worse than it really is ... Health reform is important, but would-be reformers need to remember that there are few situations that can’t be made worse by misguided change.10 Nevertheless, various initiatives were introduced, particularly significant increases in GP Medicare rebates. In 2007, the Minister claimed that these “restored morale in general practice by boosting fulltime GPs’ average Medicare earnings by about $50 000 a year since late 2003”.10 A new governmentNicola Roxon, appointed Minister for Health and Ageing in late 2007, has established a National Primary Health Care Strategy to operate within government with advice from an external reference group that is “non-representational, with members of the group contributing on the basis of their personal experience and expertise, not in terms of any representative positions they may hold”. The reference group has 13 members: six GPs (including three academic GPs), a physiotherapist, a pharmacist, a psychologist, a general practice nurse, a midwife, a health policy academic and a consumer representative.11 Priorities of the strategy are: to better reward prevention; to promote evidence-based management of chronic disease; to support patients with chronic disease to manage their condition; to support the role GPs play in the health care team; and to address the growing need for access to other health professionals, including practice nurses and allied health professionals like physiotherapists and dietitians.12 Over 260 submissions have been received, including proposals contesting the domain of general practice. Allied Health Professions Australia supports expanding the scope of allied health professionals’ practice to include prescribing and referral rights for appropriately trained allied health professionals to prescribe a limited range of medication and refer patients/clients to other health care professionals.13 DiscussionIt is a challenge to draw general conclusions about general practice policy evolution in the period 1989–2009. GPs expect their representative organisations to defend and promote their economic and professional interests. In 2007–2008, the federal government outlaid $3.6 billion on Medicare benefits for GP services, giving it some expectation that services would be delivered efficiently. The government also has a broader interest, believing that “health systems that include strong primary medical care are more efficient and have lower rates of hospitalisation”.14 Individual GPs, government officials and the Australian public may have quite different views on the developments affecting general practice between 1989 and 2009. Did general practice fail to capitalise on opportunities offered during the 1990s to more effectively secure its place in the Australian health system (eg, through the DURC and the General Practice Partnership Advisory Council)? Has political defence of the autonomy of individual practitioners to practise where and how they like forced the government to go outside general practice for solutions to issues such as ensuring that services are delivered efficiently and are available in less popular regions? Has the structure of the Medicare Benefits Schedule and other regulations encouraged GPs to vacate more complex, technical areas of medicine and move into less demanding styles of practice, thereby exposing them to arguments that lesser trained practitioners could do the job as effectively and more cheaply? Some general observations influencing recent outcomes can be made: 1. Political representation of GPs is challenging. Policy debate among Australian general practice groups is robust, often played out in the two commercially owned medical newspapers that all GPs receive each week. Many factors complicate the task: Economic priorities among GPs vary. Many work in large, bulk-billing corporate practices and have different perspectives from GPs in smaller practices in wealthier suburbs who charge fees well above Medicare rebates. Rural GPs have other issues, including onerous on-call duties, difficulty finding locums, and threats to local hospital services. There are wide differences among GPs in quite fundamental issues. Some GPs, in defending professional autonomy, reject any government involvement in shaping general practice. Others support measured, careful engagement and negotiation with government. Developments in medical science and the proliferation of specialists and subspecialists are making management decisions more complex. While many GPs seek to provide the RACGP ideal of “continuing comprehensive whole-patient medical care”,15 others retreat to niche areas such as skin cancer care. The growing prevalence of chronic illness and the preference of many doctors for a balanced lifestyle are shifting the emphasis towards team-based care. At the local level, practitioners seek arrangements that allow some flexibility in how care is organised, so that “one size fits all” solutions are less relevant than previously. Many GPs now work within large, corporately owned and professionally managed entities that provide some of the support once provided by national organisations, thus lessening ties to those organisations. 2. Over the past two decades, the direct influence of general practice national organisations has been diluted. Many medical and non-medical bodies besides the AMA and RACGP now seek to influence general practice, and the federal government exerts more direct influence over policy development than it did 20 years ago. This mirrors a broader shift away from professionally dominated processes. Perhaps Australia is catching up to the United States. Paul Starr, in his influential book The social transformation of American medicine,16 argues that, in the first half of the 20th century, organisational hierarchies within health systems and the financing of health care reflected the organised medical profession’s priorities, but the profession is now “trying to defend its prerogatives against the drive to rationalise the organisation of medical care”. Medical organisations today see “threats of two related kinds: competition and control”.16 Laugesen and Rice, in an article titled “Is the doctor in?”,17 discuss the evolving role of organised medicine in health policy. They suggest that “incentives to restrain costs [have] prompted the formation of many new organizations and interests” and that “a parallel trend of greater political pluralism in health care and expanded government roles meant new competitors entered the policy fray”. They conclude that “today a general consensus has emerged that physicians, as a group, are not as central in influencing health policy as they once were”. 3. General practice representatives now confront a vast government-funded administrative network. In 1990, the first GP adviser appointed to the federal health department sought out those staff dealing exclusively with general practice issues. After a week, he realised there were none (Jim Dickinson, former GP Adviser to the federal Department of Community Services and Health, personal communication). By contrast, in 2007–2008, there were 328 staff involved with primary care programs.18 Also, since 1989, several government-funded networks have been developed. There are 20 regional training providers supporting postgraduate GP training and a network of rural workforce agencies to support recruitment of doctors to rural areas. In 2007, the 119 Divisions of General Practice (now 111) employed 2637 staff, representing 1615 full-time equivalent staff, with aggregate infrastructure and program funding of about $200 million (about $10 000 per full-time equivalent GP).19 Divisions support GPs in ways that include organising after-hours services and providing expertise in information technology. They also provide an infrastructure for delivering federal government programs, such as visits to aged-care facilities and allied health practitioner visits to practices. The RACGP has recently questioned this aspect of Australia’s primary care organisation: The primary health care (PHC) sector in Australia is ... fragmented, under resourced, inequitably distributed, and governed from multiple points via centrally controlled, narrowly focused and frequently discontinuous programs. This creates major instability, inefficiency and frustration at every level ... The creation of multiple specific purpose general practice entities with no overarching plan and little functional connection has been a feature of the last decade.20 ConclusionsWhat do GPs coping with all the pressures of busy professional and personal lives make of all this change? Perhaps a GP considering the past 20 years of policy innovation might see parallels in a description by the medical historian Charles Rosenberg of recent health policy developments in the US: Policies on the ground seem less a coherent package of ideas and logically related practices than a layered conglomerate of stalemated battles, ad hoc alliances, and ideological gradients, more a cumulative sediment of negotiated cease-fires ...21 Australians want an individual, named GP to guide and advise them. This, as well as economic and demographic changes such as an ageing and wealthier population, the growing prevalence of chronic illness, and developments in medical science, suggest a positive future for general practice. Nevertheless, general practice policy is likely to remain a difficult and contentious area. An older Melbourne GP has described the many changes to general practice during the 1970s and 1980s resulting from the introduction of Medibank and then Medicare, and commented that “most medical graduates today probably have no concept of what general practice was like in the 1950s and 1960s”.22 Proposals floating in the policy ether in 2009 include pay for performance, blended payments with a component of capitation, physician assistants and shared electronic health records. The new national health profession registration arrangements will facilitate more fluid and possibly overlapping “scope of practice” provisions across disciplines. Perhaps, in 2030, an older GP will write that “most medical graduates today probably have no concept of what general practice was like between 1989 and 2009”.

William Coote MB BS, FRACGP, BEc

It is time to take stock of the reforms in our huge, undervalued discipline If I had my time again, I’d be a travel writer. I finished Bill Bryson’s Down under1 on the plane to Perth, Western Australia, and became inspired again about the west — the vastness and evocative timelessness of the land. As I travelled, I looked forward to catching up with old friends and meeting new ones in general practice. We were due in to do accreditation visits in the city and the Pilbara and Kimberley regions in the north-west of the state. Over the years, I’ve had the privilege of visiting over 400 practices — from Broome to Bondi and from Thursday Island to Tullamarine — for accreditation and other projects, and have been able to watch the evolution of general practice. After 3 days in Perth, we caught the early flight to Karratha, a mining town in the Pilbara region. We were struck by the isolation and heat and red rocky landscape when we arrived, but were pleasantly surprised by the practice. Corporate private practices in remote WA, established to take advantage of the mining boom opportunities, appear to be well supported. The facilities we surveyed were better than some we had visited in Perth; and the medical staff, practice manager, nurses and reception staff were enthusiastic and very capable. We interviewed one of the doctors, a Melbourne graduate recently arrived with his family, who was enjoying the work. Why did you move here? I wanted to try a different style of medicine to city practice and make a difference. What about your family? It’s a good town for kids, a lot of community spirit and people working and socialising together and there’s plenty to do, especially if you like camping and the outdoors. Later, we asked another doctor from overseas the same questions. What about your family? They used to live here but moved to Perth. [They felt] isolated and [had] nothing to do . . . I travel back on weekends. What about the medicine? There’s a lot of depression. People fly in at night and it looks beautiful, the lights and the boats on the ocean. The next morning they wake up to reality, the red landscape, the dust, the heat, the isolation. For some, “the expansiveness” of the landscape, as Thubron puts it, “becomes an obsession”;2 for others it is simply oppressive. This duality strikes at the heart of the crux of change in general practice. Some doctors and practices embrace it and see opportunities, whereas others believe that the constant changes are all about government and College control. What have reforms done for general practice?Graduating in 1978, I “grew up” medically with reform agendas in health (Box). Nothing much changes. Community health centres, the predecessors of GP Super Clinics, were first established in the Whitlam era, when I was a resident in Canberra. When I moved to rural practice in Gundagai in 1982, Medibank had evolved to Medibank “mark 2”, and finally Medicare. Ten years on, general practice accreditation — along with Divisions of General Practice, a tightening of vocational training and registration and improved uptake of information technology systems — was one of the key recommendations arising out of the 1992–93 Commonwealth Budget.3 Following on from the vocational registration debate, it was a time of intense political heat in general practice. We experienced “crash or crash through” by the Royal Australian College of General Practitioners and opposition from the Australian Medical Association, which was fearful of a nationalised health system and government intrusion into the doctor–patient relationship. I remember a meeting with the then federal Minister for Health, Housing and Community Services, Brian Howe, shortly after the Budget was released. He said something to the effect of how he would concentrate “this year on general practice, next year specialists and the year after pharmacists”. Of course, we are still waiting for accreditation of specialists and publicly funded and expansive divisions of surgery or other specialties. The government’s “reform” agenda of the 1990s didn’t go quite as planned. General practitioners weren’t paid more (until pressure was put on the system by falling bulk-billing rates much later), and the planned great reform of the Medicare Benefits Schedule based on the Relative Value Study didn’t eventuate. Governments soon used vocational registration to control entry into general practice, noting that both direct and secondary costs were rising rapidly and were related directly to the number of doctors. The brakes were applied. Medical school intakes were not increased for years and entry into general practice was limited. It was not until recently, when an ageing population, increased demand and more complex management systems brought home the stark reality of medical workforce supply, that governments acted to take their feet off the brakes. In the late 80s and 90s, the early professional agenda was about recognition of general practice as a unique discipline and addressing perceived or actual differentials between specialists’ and GPs’ incomes. GPs wanted greater recognition and higher pay. There was an expectation that a new (content-based) fee structure, introduced by the federal Minister for Community Services and Health, Neal Blewett, would usher in a brave new world for patients and better rewards for GPs. This naïve expectation appears to persist among the proponents of the new reform agenda, including Super Clinics, fund-holding by Divisions of General Practice, performance-based pay, nurse practitioners and patient registration. Medicare as a personal insurance scheme is being slowly replaced by fund-holding, grants and government largesse. This takes power away from patients and puts it into the hands of bureaucrats. It will take a lot to convince me that bureaucrats can manage general practice any better than the way they have managed the public hospital system, with its failing infrastructure, difficulties in access, bed block and inadequate mental health services. The real issue now in general practice is workforce. There are not enough doctors and not enough nurses to do the nursing, let alone become primary care practitioners. The professional, political and bureaucratic focus has been taken off this real problem as we focus on alternative funding strategies or run scared on nurse practitioners. It is far more important for the future of general practice to create vertically integrated clinics with medical students, prevocational trainees, registrars, GPs, rural doctors and specialists, and to support a personal commitment to investment in the practice. Other providers will come. PostscriptBryson would make a great GP. He seems to spend a lot of time in pubs, watching and talking with people, and longitudinal contact with people is the main satisfaction for most GPs. Bryson has a perceptive wit and is a hive of information on the interesting and remarkable. When he visited WA, he didn’t venture as far north as we had, but wanted to ring his wife, sell the house, buy a caravan and wander through the Kimberley.1 General practice has been on a journey. Every day is different. Like the country we live in, it is huge and undervalued. For some, reform in general practice hasn’t gone far enough; for others it has gone too far. There are many with vested interests that don’t necessarily parallel the interests of patients or GPs. We shouldn’t ignore the history of reform in general practice, and any changes should be based on a patient agenda rather than political or other agendas. It may be time to settle for a while and work out where we’ve been and where we are going. Port Hedland is ringed with red sand beaches. When I asked a local why there was no one swimming, she said, “Luv, if the stingers don’t get you, the sharks, sea snakes, stonefish or stingrays will”. For many GPs it is a case of once bitten, twice shy. Timeline of key reforms affecting general practice Year Reform 1974 Introduction of community health centres 1975 Initiation of Medibank 1976 Addition of Medibank levy “mark 2” and Medibank Private 1984 Introduction of Medicare 1989 Initiation of vocational registration 1989 Content-based fee structure introduced by Neal Blewett 1991 Commencement of general practice accreditation 1992 General Practice Strategy developed by government, the Australian Medical Association and the Royal Australian College of General Practitioners 1992 Freeze on increases to medical school intakes 1993 Set-up of Divisions of General Practice 1997 Completion of Relative Value Study Phase 1 2000 Increases to medical school intakes 2001 Review of 1992 General Practice Strategy 2007 Introduction of GP Super Clinics under Nicola Roxon 2009 Proposals for pay-for-performance, task transfer, and patient registration/shared electronic health records

Paul R Mara DipRACOG, FRACGP, FACRRM

Current approaches to health care reform are largely based on the metaphor of imminent flood waves threatening to inundate the health care system. This metaphor reflects the system’s preoccupation with disease and disease management in a hospital-centric environment. We suggest that the debate needs to be reframed around health, or more precisely the patient’s health experience. Most patients are healthy most of the time, and even those with identifiable morbidities generally regard themselves as being in good health. The majority of people receive most of their care in the community from primary care professionals. An integrated, effective and efficient primary health care system supports continuity of care through a primary care provider and fosters clinical leadership that is supported by other primary health care professionals and medical specialists. Each primary care setting will have its own model that best provides flexible and responsive services to meet its patients’ needs and expectations.

Joachim P Sturmberg MB BS, FRACGP, PhD · Diana E O’Halloran MB BS, FRACGP, MHPEd · Claire Jackson MB BS, MPH, FRACGP · Christopher D Mitchell FRACGP, FACRRM, FARGP · Carmel M Martin MB BS, FRACGP, PhD

The global financial crisis teaches us that systems like Medicare may have hidden long-term costs if they are based on short-term gains Dear Nic, Forgive my informality, but I have noticed that Australians like to shorten things — this even applies to Medicare. As a former TeRD (temporary resident doctor), I dreamed of being able to access Medicare for my own chronic diseases. Now I am a proud Australian citizen and grateful for the care my general practitioner gives me courtesy of Medicare. He could view me as a cash cow because my ailments make me eligible for more care plans than I’d like. Instead, he sees me and addresses my concerns when needed, and I have never felt processed or tick-boxed. Likewise, I want to give my patients quality, evidence-based and compassionate care. I love my job. I am at my best when trying to sort out what needs to be worried about and what does not. But although the Medicare system seems to be working for me as a patient, it does not work for me as a doctor. Medicare does not reward doctors who remain working in the “swampy lowland [of] messy, confusing problems [that] defy technical solution”.1 Generalists like me can ensure appropriate investigation and referral, and thus reduce costs of health care.2 GPs provide accessible and comprehensive care for common problems and provide continuity and team coordination for complex care.3 But we seem to have created an inverse care law in Australia, where specialists and GP subspecialists gain more income, and managing undifferentiated illness — often the hardest to sort out — is not rewarded. We pay premiums to people who cut out the known, not to those who draw out the unknown. To maximise this lower generalist income I am entitled to as a GP, I should conduct many consultations that last just over 5 minutes. However, taking a longer history and performing a focused physical examination (neither possible within 6 minutes) significantly increase my chances of weighing the multitude of factors that might contribute to a diagnosis or problem identification without recourse to expensive investigations (Box 1). Also, I am reminded that giving insufficient time or care to establishing a sound doctor–patient relationship and rushing consultations are two of the 10 “deadly sins” that will increase my risk of litigation.5 But this safer and, in the long term, cheaper care for my patients and my country generates less income for me in the short term. General practice grew up when most illness was acute and there were limited therapeutic options; the funding arrangements reflected the style of practice. Now, these arrangements put us in a quandary — the way to make the most money is to see people for a short time and deal with only one problem at a time. Telling people to come back for another visit seems grossly inefficient to me but is, admittedly, one way of earning a crust. Many patients want to save my and their time and bring in a list, little knowing that this will cost me income. I’ll use the example cited by the Professional Services Review (PSR), in which the clinical problems are more easily defined (a rare treat in my practice), to illustrate my less well defined billing problem. The PSR’s advice that a patient seen for a repeat script for a stable condition, an ear syringe and a blood pressure measurement would not qualify as a level C consultation even if the consultation lasted more than 20 minutes6 means that a level C consultation cannot be billed.6 However, the evidence shows that to do all three tasks well and safely is neither quick nor uncomplicated. Issuing a repeat script for a stable condition requires a check of the condition and its current impact on function, the medication, its known side effects, and potential interactions with other medications.7 The consultation should include questions about over-the-counter medications and complementary and alternative medicines (CAMs) taken, given that CAMs were reported to be used by 52.2% of 3015 people surveyed in South Australia, of whom 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor.8 According to medicolegal advice, before removing ear wax GPs should take a full history, asking specifically about ear discharge, previous perforation of the eardrum or ear infection carefully examine the external auditory canal recommend the use of wax softening agents explain the potential complications of the procedure ensure the person performing the ear syringing is fully trained ensure the equipment is correctly assembled. If the nozzle of the syringe is not properly secured, it may become detached and cause damage to the external auditory canal and/or tympanic membrane.9 The Heart Foundation’s Guide to management of hypertension 2008 recommends that doctors should “Manage identified lifestyle risk factors in all patients, whether or not BP [blood pressure] is elevated”.10 This cardiovascular risk assessment includes: personal and family history, smoking assessment, risk of diabetes, body mass index calculation, waist circumference measurement, exercise assessment, lipid assessment, and nutrition.10 Time and skills in motivational interviewing are needed to encourage change to reduce the risks identified.11 Once these simple, uncomplicated6 tasks are done, the GP should make clear, comprehensive and contemporaneous notes12 at a standard that enables another practitioner to take over care. Notes should include demographic and contact details, known allergies and a summary. Once the patient leaves, I begin my unpaid administrative work — reading letters from hospitals and emails from my Division of General Practice and practice manager; checking results; responding to patients’ queries; checking recall lists; and planning follow-up. Do you see my dilemma? Each task can be done quickly, yes, but only with potential longer-term safety risks and costs. If I do one thing per consultation, it would take three visits to deal with the problems. This has a higher overall cost in terms of making appointments for both patients and staff, patient time out of work and in travel — and what of the environmental costs of all this travel (unless I have persuaded them to cycle to the practice, thanks to my motivational interview about cardiovascular risk)? I would argue it is reasonable and good practice to do all this in one half-hour appointment and claim a Medicare Benefits Schedule item 36 long consultation. Medicare policy does not! Tell me, why not? Medicare and those practising medicine must learn the hard-hitting lesson from the current global financial crisis — that systems based on short-term gains have hidden long-term costs.13 You say you want GPs to provide quality care and include health promotion.14 Yet the announcement of increased audits of GPs’ billing practices coincides with a reduction in longer consultations of nearly a million from 5.53 million to 4.55 million between corresponding 6-month intervals in 2007–2008 and 2008–2009.15 I ask you, which do you want — short-term lower costs or longer-term better health for the people of Australia? Please value the role of the generalist; reconsider advice that “implementation of a 7 tier item structure in place of the current 4 tier item structure would improve the quality of health care in Australia” (Box 2);16 and use holistic cost–benefit analysis to inform health policy.13 Thanks for listening. Oh, and can I ask one final question? When you next need milk, will you implement the same system we apply to Medicare and just get the milk, and nothing else, on that visit to the shops? Or will you be reckless and go in with a list — wanting multiple things? Doesn’t it make much more sense to buy everything you need at once? Yours sincerely, Susan PS: please refrain from calling me Sue — I hate to be cut short. 1 A teenage girl presents to a general practitioner with recurrent headaches Option 1: brief history, referral for a computed tomography (CT) scan Time taken by GP: 6-minute consultation, 2 minutes to read report as normal, 6-minute review consultation. Income for the GP: two level-B consultations. Holistic cost–benefit analysis: cost of CT scan, radioactivity exposure for teenager, time off school and work for teenager and parent, anxiety about result, transport to and from x-ray department, return visit to the GP for brief review, but no engagement of teenager with GP to discuss emotional wellbeing, preventive or sexual health. Teenager has no understanding of tension headache. High chance of further consultations with other practitioners to establish cause for headaches. Option 2: comprehensive history and examination, no referral for CT scan Time taken by GP: 19-minute consultation giving teenager space to talk about home, education and employment, activities, drugs, depression, sexuality or suicide (HEADSS assessment tool).4 GP conducts a brief examination, then negotiates the management of tension headaches relating to upcoming school examinations and a boyfriend who will finish with her unless she agrees to start a sexual relationship. Nineteen-minute review consultation and discussion about contraception. Income for the GP: two level-B consultations. Holistic cost–benefit analysis: no expensive investigations, no exposure to radioactivity and no time off school or work or transport to attend x-ray department. Teenager understands nature of tension headaches and is able to take simple analgesics when needed. Teenager relieved to have talked about concerns and comfortable to access contraception when she is ready. 2 The Attendance Item Restructure Working Group seven-tier rebate system* The seven-tier rebate system creates a more consistent rebate per minute. At 2003 rates, this ranged from $2.00 to $2.50, whereas for the current structure, the rebate per minute ranges from $2.00 to $4.00 for consultations less than 10 minutes, but only $1.00 to $2.00 for consultations greater than 10 minutes. The proposed structure removes incentives towards consultations of just over 5 minutes. * Figure adapted from the Final report of the Attendance Item Restructure Working Group.16

Susan M Wearne MMedSc, FRACGP, FACRRM

To the Editor: The growing burden of chronic disease, an ageing population and recurring workforce pressures have been identified as three key challenges facing Australia’s health care system.1 Coping with these challenges involves developing strategies to ensure equity in access2 to health services, better preventive health measures and a more patient-centred health service — all with a focus on better health outcomes for Australians. In its discussion paper informing the development of the National Primary Health Care Strategy, the Australian Government sees general practitioner Super Clinics taking “an integrated and co-ordinated approach to delivering sustainable and efficient multidisciplinary models of care”,1 including chronic disease management in areas of high need. While laudable, this approach fails to acknowledge many of the outstanding services already available through existing community-based practices. Over the past decade, the Australian primary care landscape has seen the evolution of various forms of primary health care centres (de facto Super Clinics) — some owned and managed by practising GPs, others by corporate structures. By and large, these primary health care centres are focused on catering to the needs of local patients in the communities in which they are located. These smaller practices, often employing 5–10 GPs, provide the critical mass of Australian primary health care services.3 Many provide a broad spectrum of care —physiotherapists, podiatrists, practice nurses, occupational therapists, clinical psychologists, dietitians, counsellors, psychiatrists — that meets local community demands. This is the type of community care that deserves to receive equal priority from the Australian Government in further developing and improving local health services. The prospects for such a team-building model being successful are far more likely if the demand is “bottom-up”, with community support4 for the primary care team, rather than the government imposing a more rigid, pyramidal “top-down” model. Another approach might be for the government to provide some public services in already established primary care sector infrastructure. The possibility of taking fixed leases in established practices, as opposed to constructing large, expensive Super Clinics, would seem an obvious path and certainly merits consideration and evaluation of the benefits. Allied health professionals, practice nurses and aged-care support services could be employed to support existing on-site medical services.5 An integrated public–private sector model such as this has been used in Ireland6 and would fit well within the current Australian health structure and help consolidate the ongoing viability of many local practices. Such an approach would broaden the availability of allied health and specialist health services to many local communities, with new Super Clinics reserved for areas of genuine “high need”.1 It would also serve to send a strong message of support to primary health care professionals and their patients. The opportunity to invest in primary care infrastructure and shift emphasis onto primary care prevention deserves greater consideration.7 Local practices have largely proved their flexibility to adapt to local needs — the government should match their efforts with innovative programs that support local primary health care centres and help guarantee equity in access and services for all consumers.2

Thomas D Brett

National medical workforce registration could provide an ideal opportunity for better collection of useful workforce data The well recognised global shortage of doctors1 reinforces the need for effective medical workforce planning. Simplistically, medical workforce planning aims to ensure an adequate supply of doctors with the appropriate skills to meet the current and projected future medical care needs of the population.2 This requires accurate information about the current medical workforce,3 but Australia lacks comprehensive, timely, nationally consistent and longitudinally linked data.3,4 The principal source of Australian medical workforce data is the annual Medical Labour Force Survey, administered by each state and territory medical board on behalf of the Australian Institute of Health and Welfare as part of the annual medical registration renewal process. The survey provides data on the number of medical practitioners, their age and sex, the type of work they do, their specialties, and the hours they work.4 However, the utility of these data is limited, as they are neither timely nor comprehensive. The latest workforce report, published in 2008, reports on the 2006 survey. Response rates ranged from 80% in Queensland to 29% in the Northern Territory, although no survey data were received from the NT in 2006, necessitating estimates based on responses to the 2007 survey and weighted to 2006 benchmark figures.4 The type of practitioners surveyed varies between jurisdictions, with Queensland surveying only general registrants and conditionally registered specialists, and Tasmania excluding conditional registrants who are overseas-trained doctors or interns. Furthermore, the current survey data are cross-sectional and not longitudinally linked, limiting the identification and monitoring of factors associated with trends in changing demographics of the medical workforce.2,3 National registration of the medical workforce and the associated National Minimum Data Set Project,5 scheduled for commencement in 2010,6 could be the ideal opportunity to move Australian medical workforce data collection into the 21st century. The introduction of web-based electronic data capture for both medical registration and workforce data would facilitate timely analysis and reporting. Making the workforce survey a compulsory component of registration (with a strong and defensible rationale for each requested data item) would enable development of a comprehensive national dataset. Additional voluntary-response questions could be included to explore the factors influencing work patterns identified in subsets of respondents. Linking the workforce data to each individual’s registration number (or another “unique identifier”5) would allow monitoring of flows into and out of the workforce,3 thereby facilitating projection of trends. Expanding the workforce survey to include all general and conditionally registered medical practitioners and medical students would further enable informed modelling for workforce planning. Conditional registrations of overseas-trained doctors form a sizeable proportion of total registrations in some states (over 10% in Queensland and Western Australia in 20037) and should be included in any national data collection. The Australian Health Workforce Ministerial Council’s recent proposal to include students in the national register8 provides an avenue by which the Medical Schools Outcomes Database, which has collected demographic, educational and career-intention data from medical students across all Australian medical schools since 2006,9 could be longitudinally linked with graduate doctor data. The ways in which medical education factors (eg, school leaver versus undergraduate- and postgraduate-entry status, full fee-paying versus subsidised or bonded students, academic institution, and clinical placement experiences) influence career choices, retention and productivity could then be explored. Such a proposal is especially important for general practice workforce planning. Australia does not have enough general practitioners, and this is unlikely to change unless more doctors choose a career in general practice.10 Suggested strategies to actively encourage students to consider working in general practice include longer and higher-quality general practice attachments during medical school and early postgraduate years, such as the Pre-vocational General Practice Placements Program.11 The impact of such initiatives, including the effect of increasing the educational demands placed on the GP supervisor workforce, could be monitored through a national, longitudinally linked electronic workforce survey. Other trends affecting the supply of GPs could also be monitored. For example, the increasing feminisation of the general practice workforce necessitates greater understanding of the factors associated with female doctors’ work patterns.4 Overseas-trained doctors are relied on to provide general practice services in areas of workforce need,2 and it is important to identify the factors that influence their retention. An increasing number of GPs are restricting their clinical practice to areas of specific interest and expertise, effectively reducing the number of GPs providing undifferentiated first-contact clinical care. The actual numbers involved are not known, and while crude methods have been employed to estimate them,12 more data are required to inform not only workforce planners and policymakers, but also educational institutions seeking broad-based general practice exposure for increasing numbers of students, junior doctors and GP registrars. We welcome the planned move to national medical registration in Australia in 2010 and the development of a national minimum dataset. We urge that the labour force survey be made a compulsory component of medical registration, with adaptability to explore identified trends, and that serious consideration be given to web-based collection of the data. This would facilitate a comprehensive, longitudinally linked national dataset for the timely analysis and reporting of medical workforce data — factors considered essential for informed policy development and evidence-based workforce planning.3

Deborah A Askew PhD, MHlthSci, GradDipNutr · Naomi R Hansar BSocSci(Hons), BSc · Marie-Louise B Dick MPH, MB BS, FRACGP

To the Editor: The work intentions and opinions of general practice registrars are important in estimating the future supply of Australian general practitioners. Declining popularity of general practice has led to entrenched, long-term shortages (especially in rural areas),1,2 with 700 new entrants annually — well short of the 1100–1200 required to meet community needs.3 Between October and December 2008, we mailed questionnaires to 147 GP trainees (69% women) registered with Western Australian General Practice Education and Training, asking about their career intentions and opinions. Ethics approval was obtained from the University of Notre Dame Australia Human Research Ethics Committee. The response rate was 61% (89/147). Seventy respondents were women (79%). Median age of respondents was 30 years (interquartile range [IQR], 28–35 years). Most had graduated in Australia (82%, 73/89) and most between 2000 and 2006 (83%, 74/89). Twenty-nine per cent (26/89) made their career choice in the first 2 years after graduation, while others decided in their third year after graduation (26%, 23/89), or later (24%, 21/89); medical school was the next most common stage at which respondents made their choice (20%, 18/89). Forty of the 89 registrars (45%) were working eight or less sessions per week; 34 (38%) were working more than eight; and 15 (17%) had not yet started work. Registrars favoured rural, outer metropolitan and metropolitan areas equally as practice locations (Box 1). Becoming a practice principal was not a priority, probably reflecting respondents’ current training status and uncertainty about the future. Low numbers were planning to undertake home, nursing home or hostel visits. Using a five-point Likert scale, respondents rated flexibility and better lifestyle of general practice as major influences on their career choice (median score, 5; IQR, 4–5). Appraisal of own skills and aptitudes (median score, 4; IQR, 3–4) and intellectual influences (median score, 3.5; IQR, 3–4) were other important factors. Twenty per cent had converted from another specialty. Reasons for changing specialty included work demands and stress (50%) and career flexibility, lifestyle and family reasons (33%); in previous research, these were found to be key determinants favouring general practice as a career option.2 Obstacles to general practice selected by respondents were, in descending order of frequency: increasing bureaucracy, workforce shortages, the poor image of GPs and poor remuneration (Box 2). Increased exposure to general practice via rural clinical schools and clinical attachments as a medical student and pre-vocational doctor has been shown to be a positive influence on future GP career choices.2,4 We found the first 3 years after graduation were the most important in making career decisions, supporting earlier research5 and highlighting the potential benefits that exposure via the Prevocational General Practice Placements Program (PGPPP) brings to general practice. Suggestions that the PGPPP be open to Australian medical graduates in their first and second postgraduate years2 deserve support. Despite survey limitations of sample size and an over-representation of women registrars, our findings reflect the views of 60% of current WA GP registrars. Fifty-one per cent planned to retire at 65 years or above, and 44% planned to retire before then, with the rest unsure. Involvement of experienced GPs in health care delivery is also waning (as we outline in Retirement intentions of general practitioners aged 45–65 years).6 Recruiting and training new doctors in sufficient numbers to replace retiring experienced colleagues is critical in redressing the balance and meeting future workforce demands. Strategies to make general practice a more attractive career option for new doctors deserve increased priority if general practice is to remain a competitive discipline. 1 Work intentions of study respondents (n = 89) No. of registrars Intended practice location Metropolitan 23 (26%) Outer metropolitan 24 (27%) Rural 28 (31%) Combination 13 (15%) Unanswered 1 (1%) Position Practice principal 16 (18%) Other 72 (81%) Unanswered 1 (1%) Practice size Solo 1 (1%) 2–4 19 (21%) 5 + 43 (48%) Unsure 26 (29%) Sessions worked per week < 5 13 (15%) 5–8 55 (62%) > 8 17 (19%) Unsure 3 (3%) Unanswered 1 (1%) Out-of-surgery visits Indigenous health 21 (24%) Home visits 16 (18%) Nursing home/hostel 24 (27%) 2 Factors considered by general practice registrars to be obstacles to general practice* (n = 69) * Percentage frequencies of the 69 participants who gave answers to the open question “What do you see as the major obstacles to general practice in Australia?” When more than one response was given by an individual participant, each response was coded and counted separately.

Thomas D Brett · Diane E Arnold-Reed · Cam T Phan · Robert G Moorhead · Dana A Hince

Objective: To ascertain the retirement intentions of a cohort of Australian general practitioners.Design and setting: Postal questionnaire survey of members of four Divisions of General Practice in Western Australia, sent out November 2007 – January 2008.Participants: A sample of 178 GPs aged 45–65 years.Main outcome measures: Intention to work in general practice until retirement; reasons for retiring before age 65 years; factors that might encourage working beyond chosen retirement age; and perceived obstacles to working in general practice.Results: 63% of GPs intended to work to at least age 65 years, with men more likely to retire early. Of 63 GPs intending to retire early, 46% gave pressure of work, exhaustion and burnout as reasons for early retirement. Better remuneration, better staffing levels and more general support were incentives to continue working for 46% of the 64 GPs who responded to the question about incentives, and more flexible working hours, part-time work and reduced workload for 41%. Of 169 participants, 65% gave increasing bureaucracy, poor job satisfaction and disillusionment with the medical system or Medicare as obstacles to working in general practice in Australia, whereas workforce shortage, increasing patient demands and diminishing lifestyle through overwork were obstacles named by 48%.Conclusion: Many GPs are planning to retire early, reflecting an emerging trend among professionals and society generally. Declining job satisfaction, falling workforce numbers, excessive workload and increasing bureaucracy were recurrent concerns of older WA GPs considering premature retirement.

Thomas D Brett MD, MRCGP, FRACGP · Diane E Arnold-Reed BSc(Hons), PhD · Dana A Hince BSc(Hons), PhD · Ian K Wood MB BS, FRACGP · Robert G Moorhead MD, FRACGP, MICGP

We describe the outcomes of a practice exchange in which an isolated general practitioner from a remote region traded work and living arrangements with a rural group practice GP. An exchange can provide an opportunity for mid- and senior-career professionals to refresh their outlook on their careers. Involving the rural medical workforce in practice exchanges can enable the development of peer networks that can improve retention of isolated practitioners in Australia. A fresh experience in a new setting can provide opportunities for practitioners to improve practice management and sharpen their clinical skills. Uprooting families and preparing homes for unfamiliar visitors add stress to doctors and their families on exchange. Patients in isolated practices could feel concerned that they may lose their doctor as a result of an exchange. In this instance, the benefits far outweighed the difficulties.

John G Moran MB BS, FACRRM · Sue L Page BMed, FRACGP, FACRRM · Hudson H Birden MPH · Louise M Fisher BMed, BA(Hons), FRACGP · Naree J Hancock

In 2008, the Australian Primary Health Care Research Institute (APHCRI) held a Primary Health Care Workforce Roundtable with practising clinicians, policymakers and researchers, which drew on Australian evidence in health care policy, systematic reviews, and expertise and experience of participants. Key recommendations for an adequate, sustainable and effective primary health care workforce that arose from the meeting included: simplifying the Medicare Benefits Schedule, which is unnecessarily complex and inflexible; effectively funding undergraduate and prevocational medical and nursing education and training in primary health care; developing career structure and training pathways for general practitioners and primary health care nurses; developing of functional primary health care teams; and using a blended funding model, comprising fee-for-service as well as capitation for patients with chronic or complex needs. A report from the meeting, detailing these policy options, was submitted to the National Health and Hospitals Reform Commission for inclusion in their deliberations.

Kirsty A Douglas MB BS, MD, FRACGP · Frith K Rayner BA, PostGradDipJ · Laurann E Yen BSc, MPsych · Robert W Wells BA · Nicholas J Glasgow MBChB, MD, FRACGP · John S Humphreys BA(Hons), DipEd, PhD

The Team Care Arrangement system has room for improvement, but can aid effective patient care Collaboration between health care professionals is recognised as a key strategy for effective care of patients with chronic disease.1 Multidisciplinary care planning involving general practitioners has been associated with improved outcomes for patients with chronic conditions.2 Care plans grew out of experience of the coordinated care trials, which aimed to optimise outcomes and resource use and were based on the principles of the Chronic Care Model.3 They were designed to coordinate care across multiple providers and involve patients in setting goals that can be achieved over 12 months, at least in part, by self-management. Subsequently, the Medicare arrangements were modified so that patients who had had both a GP Management Plan and a Team Care Arrangement (TCA) could access up to five visits to allied health professionals over 1 year under Medicare. These have been actively taken up by GPs and their patients. In 2008, there were 679 400 claims for Medicare Benefits Schedule item 723 (TCAs), at a cost of about $68 963 877.4 Despite some modifications in 2005, GPs have continued to voice discontent with the complexity of current arrangements for TCAs.5 In a viewpoint article in this issue of the Journal, Hartigan and colleagues argue that TCAs are too restrictive and cumbersome to achieve their aims (Hartigan et al).6 Certainly, care plans involve a complex series of steps, including confirming eligibility, performing a GP Management Plan, getting agreement from other providers to participate in a TCA, documenting the goals and services to be provided, giving the patient and other providers a copy of the care plan, and submitting a claim to Medicare. In response to this complexity, many GPs use care plan templates, which, although they involve goal setting and patient engagement, may result in care that is insufficiently tailored to patients’ individual needs.7 GPs and patients feel that they have to negotiate these hoops for the purpose of accessing allied health services, which may be otherwise unaffordable to many patients with chronic conditions who are on low incomes. The process is often perceived to be more of a “paper chase” than an effective means of communication and coordination.8 Written care plans developed as part of a TCA may also contribute little to improving relationships between GPs and allied health providers.7,9 Negative referrals, where patients present to their GP requesting a TCA to access an allied health provider, are particularly annoying to GPs. Engaging state community health services also remains problematic because of different funding models and possible disagreement with the GP’s priorities.10 The limitation of five allied health occasions of service is frustratingly inadequate for patients who have truly complex comorbidities. Despite all this, the idea of team care still has merit. The traditional referral system works well for medical specialist care where a single consultation is sought or the specialist is taking over primary medical responsibility. However, it is not appropriate for most allied health care, or care by medical specialists where this continues to be shared with the GP over time. There is general acceptance that GPs are well placed to coordinate primary medical care, as they can provide the continuity of care needed for coordination and engagement of patients. Establishing effective communication between team members is critical to establishing trust and clarifying roles and responsibilities.11 This has not been effectively addressed under the current TCA system. Although it provides incentives for engagement of other providers, the lack of personal interaction means that these relationships may remain weak. Even with simplified arrangements and support for networking between GPs and allied health workers, the process could still be time consuming, especially if patients are to be actively involved. Engaging other members of the practice is essential. Many practice nurses are involved in helping develop and implement TCAs, and would like to expand that role.12 The evidence of the effectiveness of TCAs is quite limited. Multidisciplinary care plans appear to be most effective with higher-risk patients, such as patients with poorly controlled diabetes rather than those whose diabetes is relatively well controlled.13 So how can the process be more functional (Box)? Many of the problems arise because of the fragmented nature of our health system and the attempt to use TCAs to control access to other services. There needs to be more emphasis on communication and on ensuring quality of care and access to a comprehensive range of care appropriate to needs. Ideally, patients could be registered on a shared database, with other providers contributing dynamic information. This would obviate the need for “paper shuffling” and allow more time for one-on-one interpersonal communication over the phone to negotiate priorities for each patient. This may also allow a more flexible approach to governing access to allied health services. In the United Kingdom14 and the United States,15 levels of care are based on the level of risk of hospitalisation. GPs have demonstrated that they can assess a patient’s level of risk and that this is acceptable to patients, although it requires additional time.16 However, the federal–state split in the Australian health system means that shared assessment is difficult. GPs need to be able to initiate and negotiate access to care according to need, rather than an arbitrary number of sessions.7 More broadly, a greater focus on development of teamwork between providers and more support for self-management is needed. Although large, integrated primary health care services may provide an opportunity for this, for the foreseeable future, providers will have to work together across distances and organisational boundaries. This does not happen by chance, but requires active facilitation.17 There is a potential role for Divisions of General Practice to facilitate formal and informal links between general practice staff and allied health providers — for example, as part of continuing education programs and in developing shared care guidelines that delineate the roles and responsibilities of providers. TCAs are a mechanism to support effective patient care. However, the challenge remains for health professionals to negotiate goals for individual patients and to communicate more effectively with each other. Care planning may be useful in facilitating more collaborative care and better outcomes for high-risk patients13 and those with complex needs. This function is impeded by procedural complexity and funding rules. Although we cannot agree with Hartigan et al’s radical prescription to replace TCAs with patient summaries,6 we agree that there is ample room for improvement in the current process. Making team care planning more functional Requirements for effective team care Existing arrangements A more functional approach Shared goals and care to be provided Care plan documented by general practitioners and mailed or faxed to providers Shared record or register initiated by the GP which contains a dynamic set of goals and a care plan contributed to by all providers Gatekeeping access to allied health services Criteria for Team Care Arrangement (chronic and complex condition) and five occasions of service in 1 year Assessment of level of risk or severity of chronic condition with graded access to service according to need Shared understanding of roles and responsibilities Written care plan approved by providers and patients Shared guidelines and role descriptions negotiated by Divisions of General Practice. Direct negotiation of patient goals between clinicians for patients with complex needs via phone or in person (if collocated) Communication between providers Shared care plan mailed or faxed and written reports Informal and formal communication via professional networking and shared records

Mark F Harris BS, MD, FRACGP · Bibiana C Chan BAppSc, MA, PhD · Sarah M Dennis MSc, PhD

Objective: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia.Design: Case-study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance.Setting and participants: Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007.Results: Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability.Conclusions: Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.

John Wakerman MTH, FAFPHM, FACRRM · John S Humphreys BA, DipEd, PhD · Robert Wells BA · Pim Kuipers BA(Hons), MHumServ, PhD · Judith A Jones BA(Hons), GradDipAppSc(Comp), MSPD · Philip Entwistle PhD · Leigh Kinsman BHSc, MHSc

Objective: To describe the evolving roles of practice nurses in Australia and the impact of nurses on general practice function.Design, setting and participants: Multimethod research in two substudies: (a) a rapid appraisal based on observation, photographs of workspaces, and interviews with nurses, doctors and managers in 25 practices in Victoria and New South Wales, conducted between September 2005 and March 2006; and (b) naturalistic longitudinal case studies of introduced change in seven practices in Victoria, NSW, South Australia, Queensland and Western Australia, conducted between January 2007 and March 2008.Results: We identified six roles of nurses in general practice: patient carer, organiser, quality controller, problem solver, educator and agent of connectivity. Although the first three roles are appreciated as nursing strengths by both nurses and doctors, doctors tended not to recognise nurses’ educator and problem solver roles within the practice. Only 21% of the clinical activities undertaken by nurses were directly funded through Medicare. The role of the nurse as an agent of connectivity, uniting the different workers within the practice organisation, is particularly notable in small and medium-sized practices, and may be a key determinant of organisational resilience.Conclusion: Nurseing roles may be enhanced through progressive broadening of the scope of the patient care role, fostering the nurse educator role, and addressing barriers to role enhancement, such as organisational inexperience with interprofessional work and lack of a career structure. In adjusting the funding structure for nurses, care should be taken not to create perverse incentives to limit nurses’ clinical capacity or undermine the flexibility that gives practice nursing much of its value for nurses and practices.

Christine B Phillips MB BS, MA, FRACGP · Christopher Pearce MFM, FRACGP, PhD · Sally Hall RN · Marjan Kljakovic MB BS, PhD · Bonnie Sibbald BSc, MSc, PhD · Kathryn Dwan BA, PhD · Julie Porritt RN · Rachel Yates BSc

Care plans are a decade-old program for coordinating care of patients with chronic illness. The program currently involves Team Care Arrangements (TCAs), which require all providers to agree on all management decisions contained in the plan. By contrast, conventional referral processes leave it to providers to exercise their judgement about the other providers to be involved. TCA requirements make coordination unwieldy and lack an evidentiary basis. More importantly, although care plans were introduced to encourage general practitioners to shift from an episodic to a global approach, they do not necessarily do this. The care plan objective would be better served by the development of comprehensive patient summaries.

Paul A Hartigan BA · Tuck Meng Soo MA, MB BS(Hons), FRACGP · Marjan Kljakovic MB ChB, FRNZCGP, PhD

To the Editor: Our recent study of disadvantaged rural residents’ perceptions of and experiences with health care highlighted the critically important role of general practitioners in delivering rural health care. In stage two of the study, assessing rural health and welfare needs,1 we sought out research participants who depended on income from government payments. Interviews identified that most participants and their family members had multiple chronic health concerns and relied on GPs as their local accessible health care providers for acute and ongoing treatment. As one participant noted, “the first port of call is always the doctor”, regardless of the circumstances. This will come as no surprise to rural GPs, who experience this demand on a daily basis. The shopfront or main-street location, long opening hours, crisis response service, bulk-billing, and no need for referral make the GP’s surgery the ideal health service for people with no money, no transport, and multiple needs. However, what also came through clearly in the study was that disadvantaged patients normalise poor health as the usual experience. Participants frequently expressed a sense of resignation about the services they received, and they appeared to have low expectations of intervention, other than to relieve immediate pain or distress. For example, a woman with severe gum disease presented for repeated courses of antibiotics because she could not access dental treatment — “There’s no dentist here, but I couldn’t afford it anyway”. There were many examples where proposed referrals to specialist care could not be accessed by participants because of lack of funds or unavailable specialist services. It is possible, perhaps probable, that the inability of patients to access follow-up services led to them returning to the GP with the same problem over and over again. This may be perceived by the GP as poor self-care, when in fact it is a systemic failure in health care delivery. Existing health care systems are ineffective in addressing chronic conditions related to deprived social circumstances.2,3 However, as access to care is identified in the Australian Government’s social inclusion agenda as a key factor affecting health status,4 the way general practice facilitates this should not be ignored. The GP is a vital conduit for care within and external to the health system. This gives rural practices significant control of and responsibility for promoting health and welfare services, including preventive care. There is clearly a need for a whole-of-government approach that integrates GP services in a continuum of care.

Julaine M Allan · Patrick Ball · Margaret M Alston

Objective: To ascertain the teaching load of general practices, the capacity for expansion of general practice-based teaching and the support required to achieve this.Design, setting and participants: Questionnaire-based survey of general practitioners and practices who were teaching medical students, junior doctors or GP registrars in partnership with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide in South Australia in 2007.Main outcome measures: Current teaching load of general practices; GPs’ reasons for teaching; capacity of practices to increase teaching loads; and support required to realise practices’ full teaching capacity.Results: In 2007, the 76 practices involved in the survey taught, in total, 326 medical students, 39 junior doctors and 84 GP registrars. Exposing students and doctors to general practice was cited most often by the 194 GP respondents as the reason for teaching. Few practices rated the support payments for teaching as adequate or fairly adequate. A number of practices were able to increase their teaching load within their current levels, with most being able to teach more medical students (39% of practices) or registrars (42% of practices). All practices able to increase their teaching load stated that their capacity to expand was conditional on extra resources, including more physical space, subsidies and teachers.Conclusion: Scope exists to increase teaching in the general practices surveyed and is related to the level, or levels, of teaching undertaken by the practices. Targeted support seems essential if practices are to increase their teaching load.

Caroline O Laurence BA(Hons), MHlthServMg, PhD · Linda E Black BA(Psych), DipAppPsych, MAPS

Major developments in medical education in Australia include increasing the numbers of students and educating more students within the community and in regional, rural and remote settings. Rapid growth of student numbers and the rural orientation of the James Cook University medical school course has meant that northern Queensland had to deal with these issues earlier than other regions. One solution has been to transform some rural hospitals into teaching health services. Two hospitals that have successfully made this transformation, and another on its way, suggest that important factors include local commitment to quality clinical services, medical and academic leadership, coordination of local resources, community support, and strategic links between key organisations. Transformation to a teaching health service involves senior doctors functioning as true consultants with cascading supervision as in the traditional consultant–registrar–resident model. As both clinical and teaching capacity develops, the workforce may stabilise, infrastructure and teaching culture are established, and long-term recruitment and retention strategies emerge. Applying these models in other rural and community settings may make it possible to manage the increased training capacity and address workforce needs without compromising the educational experience — indeed, it may be enhanced.

Tarun K Sen Gupta FRACGP, FACRRM, PhD · Richard B Murray FRACGP, MPHTM, FACRRM · Neil S Beaton MRCGP, DA, FACRRM · David J Farlow FACRRM · Clare B Jukka FACRRM, GCET · Natasha L Coventry BSc, DRANZCOG, FRACGP

To the Editor: Attachments to general practices offer medical students exposure to patients and to the prevention, diagnosis, treatment and palliation of the spectrum of illness in the community. However, medical schools face the challenge of retaining, recruiting, training and supporting teaching practices that can provide high-quality learning experiences for increasing numbers of medical students, and can keep student teaching manageable and rewarding for the general practitioners themselves. We conducted semi-structured interviews with 55 of Brisbane’s practice-based GP teachers, to explore their views about teaching third-year University of Queensland medical students. Interviewees identified a number of rewards and challenges associated with supervising a medical student in the context of the “busyness” and business of everyday general practice (Box). Rewards included the intrinsic joy of teaching and mentoring; the satisfaction of a sense of obligation to teach; the opportunity to showcase high-quality general practice; the intellectual stimulation of having their practice observed and, at times, questioned; the exposure to current medical knowledge and young enthusiastic students; and an appreciation that patients themselves benefit from their participation in a teaching consultation. Other attractions identified were the availability of continuing medical education points, the federal government’s Practice Incentives Program payment of $100 per teaching session,1 and access to the University of Queensland library resources. Challenges frequently cited included managing the extra time taken to teach without excessive delays for waiting patients; and the extra workload of addressing the students’ learning needs while ensuring that the patients’ needs are given priority. Other challenges included losing income from the reduction in patient load during teaching consultation sessions; anxiety about patient acceptance of active student participation in consultations; concerns about potential negative impacts on patients of inappropriate or inexpert student comments or skills (and possible medicolegal implications); and the extra demands of supervising a relatively weak or apparently unenthusiastic student. There were also problems related to practice infrastructure, with only a third of the GPs consistently having access to a room for student consultations and study. We have identified a number of factors that motivate GPs to teach, and others that act as disincentives. The difficulties of recruitment and retention of high-quality teaching practices in the current climate of general practice workforce shortage and increased medical student numbers are likely to increase, unless practice-based teaching remains manageable and rewarding for GPs. Strategies to promote and enhance the rewards of practice-based teaching, and overcome perceived obstacles, will be needed. Themes identified in responses of 55 general practitioners to an open question about rewards and challenges of teaching (in order of frequency of expressed theme) Time management: ”There’s the stress of running behind. I pride myself on keeping to time, and I tend to be further behind with more interested students — good students get better teaching.” Intellectual stimulation and reflection: “It keeps you up to date. Makes you concentrate on what you do, challenges you to think it through.” Negative impact on patients: “The patient can hold back when there’s a student present, maybe not raise important psychosocial or emotional issues, even if they were the primary reason for presenting.” Cognitive overload: “My brain’s ringing at the end of the day.” Intrinsic difficulties of teaching: “It’s challenging to teach general practice decision making and management in a single consultation because the process is often spread over several consultations . . . and an often long history with the patient.” Intrinsic satisfactions of teaching: “I enjoy teaching. Doctor actually means teacher; it’s part of the job.” Good company: “It’s fresh faces, and connections with new people. Often there’s no opportunity to speak to my colleagues. We can work through things together, bounce off ideas.” Less good company: “I had a rude student who said to me ‘General practice is just about patting people on the back — you don’t really do anything, do you?’ I found this offensive.” Exposure to student knowledge: “Students are someone to bounce ideas off, can keep you on the ball with their recent knowledge. Or students can help by researching a problem diagnosis.” Celebrating general practice: “It makes me more enthusiastic about general practice, reminds me what a highly privileged position a GP has.” Exposing general practice: “Students may see general practice as ‘too hard’ — but this may be realistic.” Obligation to teach: “Teaching is an obligation — people did it for us.” Positive impact on patients: “Patients appreciate the banter; they can see the process. Patients love the student being involved.”

Nancy J Sturman · Patricia M Régo · Marie-Louise B Dick

How you can use the evidence to improve your patients’ outcomes The most recent edition of Heart Foundation guidelines for the management of hypertension is an evidence-based and practical guide for doctors.1 It is self-evident that clinical guidelines need to be used by doctors if they are to improve population health outcomes. Despite publication of multiple editions of the hypertension guidelines, blood pressure (BP) control in Australia is less than ideal.2 The reasons for this are varied, and include health system, doctor and patient factors.3 Here, I outline simple but effective strategies for addressing some of the doctor factors associated with lack of BP control (Box), based on the Heart Foundation guidelines and supplemented by research conducted in Australian general practice. These strategies should help protect patients from stroke, myocardial infarction and other major organ damage, and are all practical in the general practice setting. Although they will not lead to universal control (because other factors are at play), they should help protect against therapeutic inertia and doctors’ doubts about their own self-efficacy — issues that may adversely affect patient health. Get blood pressure measurements from a variety of sources. When doctors measure BP, the measurements they record may differ from the true values, because of measurement error, “white coat effect”, poor technique, single measurements, observer error, and data misinterpretation.4 These problems can be addressed, to some degree, in a variety of ways. One approach is to have someone else, or something else, record BP for adult patients. In clinical practice, BP should be measured repeatedly (and preferably by a nurse) — three times, 5 minutes apart, and the last two measurements averaged. The process can be automated with some oscillometric devices, which further reduces bias.4 Away from the practice, the patient can record their BP on a validated,5 regularly serviced machine that they have been taught to use, or they can have their BP recorded by an ambulatory BP monitor. The latter are superior predictors of hard clinical endpoints compared with clinical measurements.6 Specific advice about technique for patients (as well as clinicians) is covered in the chapter of the Heart Foundation guidelines entitled “Measuring blood pressure”.1 Repeated measurements help reduce measurement error and variability, but they need to be interpreted logically. Suitable home BP monitoring can be achieved by asking the patient to measure BP in the morning and evening, to do so twice on each occasion (2 minutes apart after sitting quietly for 5 minutes), and to record the second measurement in a spreadsheet or diary for use at their next appointment. Interpreting the data can be as simple as highlighting elevated measurements, calculating the percentage of elevated systolic and diastolic measurements, or averaging the measurements. The goal is all or nearly all measurements (or average BP) at or below target levels. When interpreting the data, remember that cut-points are lower for recordings made away from the practice; for example, 135/85 mmHg is the cut-point for BP measured away from the practice in patients with uncomplicated hypertension. Act on absolute risk. In cases where repeated measurements of elevated BP are recorded in at-risk individuals, general practitioners may still not initiate or intensify BP management. Barriers to initiation or adjustment of drug therapy include: clinical uncertainty about underlying true BP and distrust of the technology used to measure BP; distrust of the evidence underpinning the recommendations for management of hypertension; a perceived increased rate of adverse events associated with drug therapy among older patients; perceived patient attitudes towards drug therapy or the need for it; a lack of internal motivation on the part of the practitioner; and health system issues such as lack of time in consultations. The decision to initiate treatment of elevated BP should not be based on BP alone (unless it is very high). An absolute cardiovascular disease risk score should be used, such as the recently released Australian cardiovascular risk charts, that now include risk for Aboriginal and Torres Strait Islander peoples.7,8 This is a more holistic approach than use of a single risk factor — it integrates all risk factors and thus more accurately identifies at-risk individuals. In primary prevention, population risk calculators are required as doctors cannot reliably estimate absolute risk.9 Patients with mildly elevated BP, who are at low absolute risk, do not require drug therapy but still need action on lifestyle factors that affect BP (eg, alcohol intake, diet, overweight/obesity, and physical inactivity). Don’t neglect behavioural factors. GPs recognise that behavioural factors underlie elevated BP and mitigate against effective BP control, but may feel that they have limited influence on their patients’ lifestyle. However, brief advice from a GP is the most cost-effective intervention for smoking cessation.10 Also, walking is a simple, free, all-year activity that GPs can recommend. For overweight patients, caloric restriction can be recommended and, for all patients, recommendations that can be considered include moderation of alcohol intake (do not recommend alcohol to non-drinkers), restriction of salt intake (by reading and interpreting processed food labels), and consumption of fruit and vegetables (two serves of fruit and five serves of vegetables per day). Advice should be supplemented with appropriate referrals (eg, to a dietitian). Accept that most patients will need more than one drug. Most patients will need more than one drug to control their BP.11 This is exacerbated by the need to manage the clustering of risk factors and multiple morbidity, which is common among patients, and especially older patients, with high blood pressure. These factors drive a high evidence-based pill count, which should be distinguished from unnecessary polypharmacy. Thus, the need for two or more drugs to effectively manage hypertension should be communicated to patients from the outset. Follow the guideline recommendations for combinations of drugs. Ways to deal with the necessary polypharmacy in managing high BP in at-risk individuals include: minimising side effects by starting with low doses (especially in older patients and patients with renal impairment), using low-dose combinations, discontinuing ineffective drugs, avoiding agents contraindicated for other conditions that are present, and monitoring for adverse outcomes such as renal impairment; minimising cost by using fixed-dose combinations, generics, agents with a larger number of daily doses dispensed, and drugs listed on the Pharmaceutical Benefits Scheme (avoiding “brand premiums”); increasing adherence by using combination therapies (especially those that allow within-combination dose adjustments); and reducing polypharmacy across morbidities by choosing antihypertensive agents that are indicated for other diseases that are present. Treat to goal. Once treatment of high BP has been moved to an absolute risk basis, the goals are logically reduced to lower levels for those individuals who are at high absolute risk. For example, the guidelines recommend lower BP targets for increasing levels of proteinuria in patients with chronic kidney disease.1 These patients will require greater individual risk factor reduction to reach low risk than patients who are at intermediate risk. This means more drugs, higher doses, higher costs, and greater difficulty in reaching therapeutic targets. In cases where the goal is not being reached, assessing for adherence to drug therapy is important — especially during the initiation of drug therapy. Participants in the Second Australian National Blood Pressure Study who answered yes to the question “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death than those who answered no.12 Strategies for dealing with necessary polypharmacy will also help reach the goals of target BP and adherence to drug therapy. The five ways together. Combining these strategies will help to improve BP control via an evidence-based chain of action: obtaining BP measurements systematically, in and away from the general practice setting; stratifying patients according to absolute risk, and acting on risk; considering behavioural measures for all patients; and utilising drugs (usually two or more) for patients who are at high risk, to reach recommended, targeted goals. Simple evidence-based strategies for managing high blood pressure in general practice Get blood pressure measurements from a variety of sources Act on absolute risk Don’t neglect behavioural factors Accept that most patients will need more than one drug Treat to goal

Mark R Nelson MB BS(Hons), FRACGP, PhD

Objective: To evaluate the effectiveness of a multifaceted educational intervention for general practitioners to improve the outcomes of older people with asthma.Design: Cluster randomised controlled trial.Participants and setting: 42 GPs recruited from metropolitan Melbourne between 1 August 2006 and 31 July 2007, randomly assigned to an intervention or control group, and 107 patients with asthma, aged 55 years or older (consecutive patients recruited by the GPs).Main outcome measures: Evaluation by means of a videorecorded consultation with a simulated patient for GPs; and for patients, asthma control and quality of life, lung function and action plan ownership at baseline and at 4 months.Results: GPs in the intervention group scored significantly higher than those in the control group for the content and style of their consultation with simulated patients. At 4 months’ follow-up, there was no significant difference between patient groups in the asthma control scores, asthma-related quality of life or lung function.Conclusion: This trial showed an improvement in GPs’ performance in delivering asthma care to older people. Despite this, there was no significant improvement in patient outcomes.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12607000634471.

Dianne P Goeman MAppSocRes, PostGradDipSoc · Lena A Sanci PhD, FRACGP · Simon L Scharf MD, FRACP · Michael Bailey PhD · Robyn E O’Hehir FRACP, PhD, FRCPath · Christine R Jenkins MD, FRACP · Jo A Douglass MD, FRACP

Objective: To identify potentially effective strategies to be used in the primary health care (PHC) setting to prevent, detect and manage the health problems of unemployed people.Design: A narrative review of articles on PHC-based interventions for unemployed people that were published during the period January 1985 to February 2009.Results: Seven articles with a focus on improving the health of unemployed people through assessment, management and referral within PHC settings were identified. Four were based in Australia, and the others were from Canada and Europe. Most described interventions that incorporated strategies aimed at increasing general practitioners’ awareness of the health problems of unemployed people and providing guidance on the management of these problems. One article included an evaluation of the impact of the intervention on health and social outcomes, but no impact was shown.Conclusions: There have been few formal scientific investigations into the effectiveness of PHC-based interventions for unemployed people. GPs and other community health workers have a central role in preventing, and providing early management of, the health problems of unemployed people, and supporting return to work. People who are unemployed have poorer physical and mental health than those who are employed. Research should move from describing these health problems to developing interventions that are subject to rigorous evaluation.

Elizabeth Harris BA, MPH · Mark F Harris MD, FRACGP

Lessons from the past for today’s researchers in general practice In January 1971, a randomised controlled trial of management of depression by general practitioners was published in the British Medical Journal by Tim Blashki (T G B) and his colleagues Robert Mowbray and Brian Davies (Box 1).1 Although there had been two earlier trials of antidepressants conducted in general practice (one British and one American), this was the first in the world to have extractable data in general-practice-only patients that could be used in a meta-analysis. It is therefore the earliest study included in this year’s published Cochrane Reviews that examines antidepressants versus placebo for depression in primary care; the review’s authors were Bruce Arroll (B A), Grant Blashki (G A B) and colleagues.2 Tim Blashki, the first author of this historically important article, was a Melbourne psychiatrist who had been a GP before he commenced the study. Tim Blashki’s son, Grant (G A B), has continued the family tradition of researching the management of mental illness by GPs,3 and he recently took up Bruce Arroll’s suggestion to interview Tim to document some of his experiences from this early clinical trial. This interview took place by phone on 8 January 2009. The interviewCould you say something about your medical training?I graduated from medical school in Sydney in 1964, having had only about 12 lectures in psychiatry in total. My first real contact with psychiatry was as a second-year resident at Royal Melbourne Hospital, where I worked as a medical officer under Professor Brian Davies. Psychiatry interested me and came easily to me, and this sparked an interest which has continued for the rest of my life. As a result of this experience, I went to a typical psychiatric hospital of the time. There were some very good and dedicated people working there, but, for the most part, treatments at that time were only partially effective, and there was a large custodial component in the function of the institution. My first job was unsupervised, and involved looking after a ward for young women (adolescents and those in their early 20s), many of whom had psychosis with poorly controlled symptoms. I left after 6 months and began working in general practice, as I wanted to help people experiencing mental illnesses in the community. The general practice I joined practised in a traditional manner for that time. The focus was on patients’ somatic symptoms and on somatic treatments. Patients had great faith in the doctors, whom they had known for many years in what was a rather tight-knit community. Psychological problems were generally ignored or ascribed to some somatic problem or social difficulty. Treatment consisted of support, advice, and a variety of what were essentially placebo treatments, ranging from rose-coloured water (dill water), vitamins, Waterbury’s compound, the pharmacist’s special concoction (often a bromide-containing medication), and night sedation with drugs such as chloral hydrate and barbiturates. The use of tricyclic antidepressants, monoamine oxidase inhibitors and minor tranquilisers, often in minute doses, was just beginning. Depression was just starting to be acknowledged as an illness; most depressions were perceived as reactions to events or a failure of will. Anxiety more or less went with the depression, with the exception of phobias and “panic” states. It became clear to me that much of what I was seeing in general practice — I thought about 70% — was psychologically based, and so I returned to psychiatry at Royal Melbourne Hospital, where I again worked under Professor Brian Davies. It was in this dual setting of psychiatry and of general practice that I began to think about psychological disorder in the community, and depression and anxiety in particular. How did the idea of a randomised, placebo controlled trial of antidepressants in general practice come about?In the late 1960s, I decided to do a doctorate in medicine. I chose to do this with a focus on general practice for a number of reasons. First, as I’ve already mentioned, many of the problems that I’d seen in general practice were of a psychological nature. Second, while most mental health problems were being seen in general practice, most of the research was done in hospitals on inpatients and the results were being extrapolated to general practice patients. The assumption was that these patients were part of the same cohort, but, having worked in both places, I believed this to be incorrect. Third, I was interested in the notion of placebo as an effective treatment, and I had wondered whether some of the “antidepressant effect” seen in patients treated in general practice for depression was possibly the result of such a placebo effect. Fourth, I thought that some of the response to antidepressants in this mildly to moderately affected group might be occurring because of reduced anxiety, rather than to a specific antidepressant effect. Finally, I could find very little published research on what was essentially a large group of people in the community who had some type of mental disorder. What was involved in getting the study off the ground?Initially, I had two problems. The first was that GPs were said to be not particularly interested in psychiatry.4 However, I felt that given half a chance, many GPs would respond to an offer of some help and of an opportunity to be involved in a research project. This indeed proved to be the case. It involved me visiting GPs in their practices and talking about the sorts of issues that they faced, which facilitated the study and was central to its successful completion over 9 months in late 1969 and early 1970. The Research Committee of the Victorian branch of the Royal Australian College of General Practitioners were well acquainted with the project and approved it. The second problem was that of constructing a study that had the same scientific rigour as previous studies that had been conducted in institutions, and to apply this rigour in a general practice setting. To accomplish this, it was necessary to ensure randomisation, placebo control, double blinding, and for the patients to be rated both subjectively and objectively with the use of rating scales such as the Hamilton Rating Scale for Depression5 and the Taylor Manifest Anxiety Scale.6 To confirm whether the patients did actually take the tablets that were prescribed, riboflavine was included in the formulation, and patients’ urine was tested for compliance with treatment. The coauthors of the study, Robert Mowbray and Brian Davies, made important contributions to the planning of the study. What did the study find?For me, the most fascinating and important finding was that clinical improvements occurred in 55% of patients who had received placebo after 7 days, and in 61% at 28 days. Indeed, there was a handful of patients who wanted to continue taking the placebo even after they were told it was a placebo, and we managed to obtain more placebo from the pharmaceutical company, so that they might continue taking their “medication”. With respect to the specific treatments, I was not surprised that the higher dose of amitriptyline (150 mg per day) was the most effective in relieving depression and anxiety. Anecdotally, I thought that the smaller dose of 75 mg might also be effective in relieving symptoms, but this proved not to be the case. I was interested to read a recent study by Furukawa et al, published in the British Medical Journal in 2002, in which they found a good response to low-dose tricyclic antidepressants.7 With respect to side effects, there was no difference between the groups. This was very surprising, but I think it might be attributed to a problem in the study design. Participants were given a list of possible side effects before starting the medication — something I thought to be important because some might well have been troubled with the higher doses — and this may have created a bias that was reflected in the side-effect profile across all groups. What was the social context in which the study was conducted?I have already alluded to the apparent lack of interest in psychiatry among GPs in those days, to the stigma associated with psychiatric illness, to the notion that depression was induced by life circumstances or was a failure of will; certainly, “madness” was something to be avoided at all costs. While there was some acknowledgement of a biological tendency or disposition often reflected in a family history, when this was discerned, patients were generally sent off to the psychiatrist and the case considered exceptional. The other social factor was that while women came to their doctors for treatment, men generally did not. Men saw it as a weakness, unmanly, and indicative of failure; their way of expressing their distress was often through aggression, excessive alcohol consumption or, at worst, carefully planned or violent suicide. So, I saw mainly depressed women who seemed more ready to say something about how they felt and express something of their vulnerability. Hence, the idea of studying only women in this project came to mind. What is your view of mental health management in general practice today?The management of mental health in general practice is far removed from that of 40 years ago. GPs are more educated in mental illness, and mental illness is less stigmatised. Research has provided a greater understanding of mental disorders and the treatments available, whether they be biological, social or psychological, and much therapy is now evidence-based. It is important that mental health research continue in the setting of general practice, and there are at least three important lessons for future researchers that I’d like to share (Box 2). Fortunately, mental health is now seen as a community responsibility, and there is commensurate financial commitment. Powerful support structures now exist — community, psychiatric, psychological and social. GPs have rightly become an integral part of this process. 1 About one of the world’s first randomised controlled trials of management of depression by general practitioners1 The study was a double-blind randomised controlled trial of amitriptyline (two different doses: 75 mg and 150 mg per day), amylobarbitone (150 mg/day), and placebo, for 4 weeks. It was conducted between 1969 and 1970, and involved 82 women with depressive illness, recruited from 21 general practices in Melbourne, who were randomly allocated into the four groups (61 women completed the study). Improvement at 7 and 28 days was noted on several measures of depression and anxiety in all treatment groups. Of the treatments, amitriptyline at 150 mg/day was the most consistent in relieving depression and anxiety. Troublesome side effects were equally distributed among the four groups. 2 Lessons for researchers undertaking mental health studies in the general practice setting The success or failure of research in general practice will usually depend on the trust established between GPs and their patients. All modes of treatment should be assessed in the setting in which they are to be used, and this is especially true in general practice. Research needs to be scientifically rigorous and objective, while remaining sensitive to the subjective experience of patients.

Bruce Arroll PhD, FRNZCGP, FAFPHM · Timothy G Blashki MD, MRCPsych, FRANZCP · Grant A Blashki MD, MB BS, FRACGP

To the Editor: Academic researchers and staff of Divisions of General Practice often perceive that urban general practitioners “don’t have time” to participate in various practice development or research activities, or even that they don’t have enough time overall. What does this really mean? Urban GPs can ensure that they have too little time for anything by continuing to accept new patients when they already have more patients than the number to whom they can provide timely quality care. Further, urban GPs’ apparent lack of time may be relative, rather than absolute. One GP may claim to have time to see patients, but not to write medical reports; a second GP may profess to have time to write medical reports, but not to create care plans; a third GP may claim to have time to create care plans, but not to provide home visits. The real reasons for such statements may include any one or a combination of: disliking the activity; finding the activity difficult to perform; feeling that the activity does not benefit the patient; or being able to earn more performing other activities. Dislike of the activity may explain why some GPs claim to have insufficient time for relatively well paid activities, such as writing medical reports for insurance or legal purposes. The perceived difficulty of a task may explain why some GPs say that they don’t have enough time to provide psychological help or to perform surgical procedures. Perceived lack of benefit to the patient may explain why some GPs claim that they don’t have enough time to create care plans or perform health assessments. Being able to earn more performing other professional activities may explain why some GPs say that they don’t have enough time to visit residential aged care facilities. Seeking honest, detailed explanations from GPs about their reasons for performing or not performing various activities that are believed to be useful will enable others in the health system to understand the barriers to getting GPs to perform them. Knowing the real reasons for GPs’ refusal to perform an activity will enable its promoter or sponsor to redesign it to make it more acceptable or useful. For example, when requesting medical reports, insurance companies and government agencies often request information that has already been provided on one or more earlier occasions. Asking for an update — containing only new information — is likely to increase GPs’ cooperation. Those who want more GPs to create care plans for their patients need to produce evidence of the benefits to patients of care plans. Those who wish for more GPs to visit residential aged care facilities have to find ways to make this as financially rewarding as consulting in the surgery. “GPs don’t have time” should no longer be accepted as an adequate explanation for GPs’ failure or refusal to perform particular activities. The real reasons behind such a statement should be sought, listened to and acted upon.

Oliver R Frank

To the Editor: Although many medicines transfer into breast milk, the amount received by the breastfed infant is usually low, with minimal risk to the infant.1 Because medicines are not tested on breastfeeding women, product information often states that the safety of use during lactation is unknown. This may lead to over-caution in prescribers, who may incorrectly advise women to stop breastfeeding during courses of medication.2 Even brief interruptions to breastfeeding can lead to complications, such as mastitis or breast refusal.1,2 Evidence-based assessments should be made for each mother–baby pair, depending on the baby’s age and the drug’s pharmacokinetics.2 Information about the safety of medicines during breastfeeding is available from books and websites,3 but doctors’ knowledge and use of these resources are not known. We carried out an observational study to describe general practitioners’ current and preferred sources of information about the safety of medicines during breastfeeding. We surveyed the 640 GPs who provided shared maternity care at Victoria’s largest maternity hospital, the Royal Women’s Hospital (RWH), Melbourne. A postal survey to be completed anonymously was sent in November 2007 with a reminder postcard 2 weeks later; a second copy of the survey was sent in February 2008. The study was approved by the human research ethics committees at La Trobe University, University of Melbourne and the RWH. Responses were received from 52% of GPs (335/640); most respondents were women (70%, 233/333), and most had personal experience of breastfeeding for longer than 6 months (68% of participants or their partners, 227/333). Over two-thirds (70%, 233/335) used the Internet during consultations. Eighty-two per cent (270/331) found the Internet helpful. Most participants (73%) obtained information about medicines and breastfeeding from their software program, or from dedicated books (61%; predominantly the RWH’s Drugs and breastfeeding4), and 51% used telephone advice (predominantly from the RWH pharmacy). When asked where they would prefer to access this information, most nominated their software prescribing program (68%) or a reliable Internet database (57%) in their top three preferences (Box). Although most participants (89%, 293/331) felt confident about prescribing for breastfeeding women, the majority were not aware that ibuprofen is considered safe for breastfeeding women; only 31% (102/330) agreed that “there is no problem taking this medicine while breastfeeding”. It appeared that some GPs erroneously believed that pregnancy drug ratings also apply to breastfeeding women. Ibuprofen has a category C pregnancy rating (drugs that have caused or may be suspected of causing harmful effects in the human fetus or neonate without causing malformations), yet the product information from Reckitt Benckiser (Slough, United Kingdom), the manufacturer of Nurofen, states that “no harmful effects are known in breastfed infants”.5 An additional problem is the contradictory advice given by different sources;6 another manufacturer, Abbott, does not recommend ibuprofen for breastfeeding mothers.5 As recommended by researchers in the United States, “We should replace the assumption ‘when in doubt, don’t breast-feed’ with the mandate ‘when in doubt, look it up in a reliable source’”.6 A central accessible source of up-to-date information about individual medications and lactation is urgently needed.7 Most GPs in our study would like this information available on the Internet. Sources of information used by general practitioners when prescribing for breastfeeding women No. of GPs (n = 332) Current sources* Preferred sources† Software prescribing program 242 (73%) 226 (68%) Reliable Internet database 33 (10%) 191 (57%) Dedicated books 203 (61%) 146 (44%) Australian medicines handbook 109 (33%) 125 (38%) Printed guidelines 0 112 (34%) Telephone advice 168 (51%) 106 (32%) Conference/seminars 2 (0.6%) 23 (7%) Journal articles 68 (20%) 19 (6%) One-on-one educational visiting (academic detailing) 0 10 (3%) Printed product information (eg, MIMS) 181 (55%) 3 (0.9%) Therapeutic guidelines 33 (10%) 3 (0.9%) Previous experience 202 (61%) 0 Pharmacist 71 (21%) 0 Colleagues 61 (18%) 0 Other books 3 (0.9%) 0 MIMS = monthly index of medical specialties. * More than one option permitted. † GPs were asked to number their top three preferences.

Lisa H Amir · Marie V Pirotta

To the Editor: One of the most talked about solutions to some of the problems of our health care system is “preventive health”. The rationale appears to be that “an ounce of prevention is better (and presumably cheaper) than a pound of cure”. Perhaps this is the reasoning behind the ever-increasing Medicare Benefits Schedule item numbers, inducing general practitioners to do more and more preventive health checks. This is expected of GPs, conditional on the services being “cost neutral” to the government.1 Reasonable as it sounds on the face of it, this may be neither efficient nor cost-effective, given that: most preventive health issues (such as asthma, diabetes, obesity, hypertension and stroke) can not be covered reasonably well in less than several hours or several long consultations, depending on the educational level of the target audience; Medicare Australia appears reluctant to pay a fair fee for these long consultations without imposing a lot of red tape; and the average patient seeking such preventive health advice is usually middle-aged or older, and the opportunities for true prevention (rather than risk factor management) may have long passed. A better solution to this predicament may lie in changes to school curricula. Any time spent on general common-sense health and hygiene topics in high schools would be cheaper to provide (costing only tens of dollars per hour if provided by teachers versus hundreds of dollars if provided by GPs). Health education in schools may also help students establish a healthy lifestyle from a young age, benefits of which could be reaped for decades. In other words, health education may have to become a compulsory part of the curriculum for prospective teachers. Local GPs could give lectures on health education to aspiring teachers. Topics could include the importance of adequate sleep, adequate exercise and an adequate intake of fresh fruit and vegetables on a daily basis; the hazards of smoking and drinking; and mundane but important areas such as simple hygiene practices, skin care and even dental care. If more patients had some basic knowledge of these and many other common topics, such as the differences in symptoms and natural history between viral and bacterial respiratory infections, the number and length of GP consultations could potentially be reduced. This, in turn, would have a direct flow-on effect on the overall efficiency of the primary health care system and, undoubtedly, the tertiary health care system as well.

Tony A Marshal