Volume 193 Issue 2

General practice is being asked to handle patients with more and more complex conditions By the time this postcard arrives, the United Kingdom will have a new government. One of its major tasks will be to wrestle with the problems of the National Health Service (NHS) in a tight financial climate in which it will be difficult to provide significant increases in NHS funding for the next 3 or 4 years at least. The NHS has enjoyed a massive injection of cash over the past 5 years, and although many aspects of the health service have improved, including access to secondary care, cancer care and waiting times for treatment, there are still many areas of concern. The consequences of membership of the European Union include free movement of heath care professionals, which has led to poorly trained and linguistically challenged doctors working dangerously long hours in the UK; and the European Working Time Directive, which has raised serious concerns about the adequacy of medical training and patient safety. In the cities, the perverse incentives for general practices to employ salaried staff, rather than profit-sharing partners, threatens the survival of the partnership system. The political parties have proposed a range of policies aimed at protecting NHS funding and maintaining “front-line” services. These include, predictably, reducing bureaucracy and waste, and working more efficiently. Ideas to achieve this include: abolishing primary care trusts (PCTs) and replacing them with locally appointed and locally elected health boards; scrapping the disastrous and hugely expensive centralised information technology project, “Connecting for Health”; and reducing by a third the amount spent by the Department of Health on advertising and publicity. One of the Labour Party’s ideas was to rename the Department of Health as the Department of Public Health, emphasising the importance attached to preventive medicine and health promotion. The Labour government has also set great store by its QIPP (Quality, Innovation, Productivity and Prevention) program, much of which is designed to encourage collaboration between primary and secondary carers, particularly for patients with long-term conditions. This is welcome, because consultants and general practitioners seem to have drifted apart again in recent years, perhaps partly because of the way that funding at PCT level encourages a competitive rather than collaborative approach to service design. Perhaps the Labour government’s most controversial proposal — and one definitely not designed to save money — was to introduce a state-funded social care system, along with arrangements to support the costs of end-of-life care for the elderly. It is difficult to see how, in the present financial context, such proposals can be entertained without a massive rise in personal taxation. The 2008 inquiry led by Sir John Tooke1 recommended an extension of training for general practice to 4 or even 5 years, and it was disappointing to hear recently that these proposals have not been supported by the body overseeing postgraduate training in the UK. This is a great shame, because not only is the UK out of step with GP training in many other countries, but also the increasing “secondary–primary care shift” in the focus of care means that general practice is being asked to handle patients with more and more complex conditions. This requires adequate, often additional, specialist-based training, as well as more time in practice, and may also have implications for undergraduate teaching. After all, about half our qualifying doctors become GPs, and the task of general practice is becoming more demanding by the year, as GPs are required to deal with populations with changing demographic, ethnic and cultural characteristics, not to mention new infectious diseases and new twists on the old, non-communicable ones. Finally, general practice may need to take a hard look at itself. The new contract and the introduction of the Quality and Outcomes Framework resulted in considerable increases in income for many GPs. The withdrawal from out-of-hours responsibility, along with fragmentation of continuity of personal care, are considered by some to threaten the core values of the discipline and may not have done much to endear us to our patients. Proposals are welcome for GPs to resume responsibility for providing out-of-hours services, to become more engaged in local service redesign and delivery, and to reinvest efficiency and innovation savings in their practices.

Roger H Jones DM, FRCP, FRCGP

How are the government’s reforms progressing, and what impact will they have on general practice? On 24 November 2007, the people of Australia elected a new Labor government, which promised to reform Australia’s health system, with a strong commitment to primary health care and general practice.1,2 Following the election, the National Health and Hospitals Reform Commission was established,3 along with taskforces to develop a National Preventative Health Strategy4 and a National Primary Health Care Strategy.5 Two and a half years later, the recommendations of each of these taskforces have now been delivered. The final report of the National Health and Hospitals Reform Commission, released on 27 July 2009, focused on building on “the vital role of general practice” to strengthen primary health care as the “cornerstone of a future person-centred health system”.6,7 Following the report’s release, the Prime Minister and the Minister for Health and Ageing conducted extensive consultations with health care providers and consumers across the country. The initial focus was on hospitals, but this was rapidly followed by community-based consultations, including visits to general practices. National Health Reform Plan — stage oneOn 3 March 2010, Prime Minister Rudd announced the first components of the Australian Government’s National Health Reform Plan8 and advised the nation that the changes represented the “most significant reform of Australia’s health and hospital system since the introduction of Medicare”.9 In his speech, which outlined reforms to be achieved largely through funding, structural changes and national standards,10 the Prime Minister advised that the Australian Government would become the majority funder of public hospitals and take over responsibility for general practitioner and primary health care services.8,9 As the Prime Minister entered into negotiations with the states and territories and debated concerns about the continuing federal–state sharing of responsibility for public hospital funding, the attention of the media and many commentators was firmly focused on public hospitals and the establishment of local hospital networks. However, the Plan also advised that Currently, the Commonwealth subsidises privately provided GP and some nursing and allied health services. States provide a range of services including community health centres, subsidised GP clinics, allied health services, child and maternal health clinics, drug and alcohol services, and community mental health services ... This important structural change ... means that one level of government — the Commonwealth — will be responsible and accountable for the strategic direction, planning and public funding of primary health care.8 There was little explanation provided at the time on how this would be achieved, although the Plan advised that The Commonwealth will take funding and policy responsibility, but services will continue to be provided by a wide range of providers including the private sector, community organisations, local councils and state governments. MBS [Medicare Benefits Schedule] arrangements that underpin privately practising GPs will remain in place.8 The Plan outlined that the move to federal funding of primary health care programs currently funded and provided by states would occur from the 2011–12 financial year.8 National Health Reform Plan — stage twoOn 12 April 2010, stage two of the government’s National Health Reform Plan was released.11 The Prime Minister and Minister for Health and Ageing announced the establishment of a nationwide network of primary health care organisations [that] will support GPs and other health professionals to improve the delivery of primary care services at the local level [by] working with Local Hospital Networks to assist with patients’ transition out of hospital, and where relevant into aged care; and delivering health promotion and preventative health programs targeted to risk factors in communities ... Primary health care organisations will be built from the existing network of Divisions of GPs so that they don’t create additional bureaucracy. The first primary health care organisations will be established by mid 2011.12 This was followed by the federal Budget announcement on 11 May 2010 of a “$1.2 billion boost to GP and primary health care to deliver real improvements in frontline health services for patients across Australia” through the establishment of the network of primary health care organisations (PHCOs), investment in general practice infrastructure, a program to improve care for people with diabetes, and additional support for nurses working in general practice.13 Primary health care organisationsThe federal Budget announcement outlined that PHCOs would be known as Medicare Locals. The first priority of Medicare Locals will be to coordinate the expansion of access to after hours GP services, which will be linked to a new 24 hour national telephone-based service ... Over time, Medicare Locals will also support community health promotion and prevention programs, and take a greater role in community-based mental health service provision ...13 PHCOs provide a much anticipated opportunity to strengthen primary health care and deliver improvements in the health of communities and the coordination of care, especially for people with chronic health conditions. This announcement ended the uncertainty hanging over the future of the nation’s network of Divisions of General Practice, but provided scant detail on how transition to PHCOs will occur and how the talents and commitment of the thousands of people working in Divisions will be retained. It remains unclear how PHCOs will link with each of the new local hospital networks and how these two separate regional entities will complement each other instead of simply expanding the “blame game”. These changes in regional governance of health care will require skilled chairs, board members and chief executive officers, along with strong and meaningful engagement with and responsiveness to local communities and to local clinicians who are committed to providing high-quality care to the people of their region. The PHCOs will also face the challenge of diminished GP ownership, while bringing together the diverse cultures of the many facets of community-based health care delivery, including tens of thousands of health care professionals funded by states and territories. A Council of Australian Governments (COAG) announcement on 20 April 2010 advised that a National Performance Authority for local hospital networks is to be established,14 but it is unclear what oversight it will have over PHCOs and individual general practices. The Authority will implement “Healthy Community Reports” on primary health care performance.14 It is hoped that the key performance measure will be whether or not all the people of this nation are receiving the best possible care with the best possible outcomes. Investment in general practice infrastructureAlthough the roll-out of some of the 36 already planned GP Super Clinics has been delayed,15 the 2010 federal Budget provides $355.2 million to build yet another 23 GP Super Clinics and to allow more than 400 general practices and other primary care clinics to build expanded facilities to provide space for teaching and expanded clinical services.13 There is growing enthusiasm for the opportunities Super Clinics may offer for research into new models of care, as well as innovations in interprofessional learning in community-based settings. Improved care for people with diabetesStage two of the National Health Reform Plan included the announcement of a new $436 million program to support coordinated care of people with diabetes. For the first time, patients diagnosed with diabetes will have the option to enrol with a general practice of their choice to receive high quality coordinated care ...11 The government announced an annual payment to general practices for every enrolled patient “to cover the costs of the patient’s day to day GP primary health care and additional services”.11 The program generated immediate concern and confusion, with one poll revealing that most GPs were not convinced of the program’s worth or feasibility.16 The program risks encouraging perverse incentives to enrol people with mild diabetes and to avoid enrolling those with complex care needs. It remains unclear how the program will support improvements in the care of all people with chronic disease and the implications for the many people with diabetes who have comorbid chronic health problems. It also puts the focus of general practice reform firmly on chronic disease management, which, while important, is only one facet of the responsibilities of general practice. Additional support for nurses working in general practiceIn a significant change to primary care workforce funding, on 24 June 2009 the Minister for Health and Ageing announced the introduction of legislation to provide nurse practitioners with access to the MBS and Pharmaceutical Benefits Scheme for the first time.17 This has now been followed in 2010 by a federal Budget announcement of $390.3 million ... to better support practice nurses and, for the first time, provide funding for GPs in urban areas to help employ practice nurses. Annual incentive payments of $25,000 per full time GP for a registered nurse and $12,500 per full time GP for an enrolled nurse will be made available to eligible accredited general practices.13 While general practice organisations have been calling for an increase in support for practice nurses since practice incentive payments were introduced for nurses in rural practices in 2001, introduction of these new payments, if accompanied by removal of existing incentives, could see a reduction in federal funding for nurses in many general practices. The announcement does not provide details on how the reforms will boost the engagement of allied health professionals based in general practice, a core feature of the government’s own primary health care strategy.18 Increasing GP training placesOn 15 March 2010, prior to the federal Budget announcement, the Prime Minister and Minister for Health and Ageing announced that the Australian Government would [double] the number of places available for medical graduates to train to become a General Practitioner from 600 when the government took office to 1,200 a year by 2014 ... [and double] the number of places available for junior doctors to experience a career in general practice before they become a fully fledged doctor to 975 places a year by 2013.19 General practice organisations have been calling for an increase in training places since numbers were capped at 400 places a year in 1995. While increased training numbers are necessary to retain and build the capacity of the nation’s GP workforce, Australian governments need to do much more to ensure that general practice once again becomes a highly sought-after career option for a majority of recent medical graduates. Where is further reform still needed?Stage two revealed a modest investment of “$96 million over the next four years to increase financial incentives to GPs to provide more services to Australians receiving aged care”.11 Additional investment in aged care is welcome, but this falls far short of meeting the rising long-term care needs of ageing Australians. The stage two report advised that the government would be making further announcements on reforms in mental health, dental health, preventive health and e-health “over the coming weeks and months”.11 The federal Budget saw the announcement of a “$466.7 million investment over the next two years ... to establish a secure system of personally controlled electronic health records”,20 but made no mention of the e-health investment needed in primary care to support the wider reforms. Only minimal further investment was announced for mental health. Further significant reforms to support the health of Aboriginal and Torres Strait Islander peoples and the health of people living in rural and remote locations were missing, as was a specific focus on the social determinants of health, which may mean that many of the people who are currently disadvantaged in terms of health care access and outcomes will remain so. None of the announcements addressed the impact of climate change on human health, despite the World Health Organization Director-General stating that this is “one of the greatest challenges of our time”.21 Integration and implementation of reformsThe National Health Reform Plan is accompanied by other government reforms. In November 2008, COAG announced that the federal government would invest $1.1 billion in training more doctors, nurses and other health professionals.22 As a result, we now have Health Workforce Australia,23 with its mandate to ensure the nation has the health workforce to meet the current and future needs of our population, and with responsibility for overseeing the financial support for pre-professional clinical training, facilitating the clinical placement of students, and establishing health workforce registers to assist longer-term planning initiatives. The Health Workforce Australia program is expected to result in the training of an additional 18 000 nurse supervisors, 5000 allied health supervisors and 7000 medical supervisors,22 but there is little acknowledgement of the challenge of identifying and retaining supervisors. There is also no mooted increase in the practice incentive payment for training medical students in general practice, which has stagnated at $100 per session since 2004. These challenges are compounded by the reforms arising from a review of Australian higher education,24 which will remove caps on university enrolments for many health professions at a time when training capacity in hospitals and the community is already stretched. This may be balanced by growing capacity for clinical training in non-traditional settings, such as private hospitals, private clinics and other community-based health care settings. Integration of these government reforms is essential; otherwise the reform process risks being hampered by mixed messages and clashes in implementation. Some key aspects of reform have not yet been rolled out, such as the aforementioned delay of some GP Super Clinics. Additionally, although COAG announced an $872 million investment in preventive health programs and the establishment of a National Preventive Health Agency in November 2008,25 at the time of writing, the Bill to establish the agency was still under consideration by the Senate. Is this all real reform or a series of loosely connected new programs and initiatives that aim to produce improvements in discrete aspects of our complex health care system, but which risk a continuation of the problems of cost shifting and blame shifting? There is a risk that the announced initiatives, while providing significant increases in funding for some aspects of primary care, may not result in a fundamental shift from a system focused on hospitals and disease to a system that focuses on community-based care, health promotion and the prevention of illness. The recognition of and support for the central role of general practice, expressed by the government throughout the reform process, remains strong but needs to be matched by appropriate targeted investment that builds capacity in every general practice in the country. General practice is a proven, cost-efficient and effective model of care that centres on the needs of individuals and communities,26 and public confidence in general practice in Australia remains very high.27 The rush to reform must not put this at risk. We need to ensure that we do not sacrifice the personal responsibility of a single clinician, or team of clinicians, for an individual patient. Care delivery by multiple providers can provide benefits, but each patient still needs a trusted advocate who shares responsibility for the coordination of his or her care. The commitment of our health workforce underpins the success of Australia’s health care system. The scale of the proposed change is daunting, and the nation’s health care providers will need to be supported during the coming months of uncertainty. Any reforms need to respect the commitment of each health care professional, while at the same time engaging each of us in achieving the changes our community would like to see.

Michael R Kidd AM, MD, FRACGP

Divisions of General Practice are a significant part of Australia’s health care sector. The Australian Government intends to establish “Medicare Locals” (MLs), which will assume many of the roles currently undertaken by Divisions. MLs will, on average, be larger than Divisions and are likely to have different ownership, governance and accountability arrangements. While some Divisions may find transformation into an ML an appealing and relatively straightforward option, others may wish to follow alternative paths that allow them to maintain many of their current characteristics. Evidence suggests that the move to MLs might jeopardise the level of clinical involvement attained by Divisions.

Philip K Davies MSc, GAICD

In 2008, the Australian Government established three major health reform initiatives — the National Health and Hospitals Reform Commission, the first National Primary Health Care Strategy working group, and the Preventative Health Taskforce. We examined which journals were most frequently cited in the publicly available discussion papers, commissioned papers, submissions and final reports of these initiatives. Journal articles were cited most in discussion papers, commissioned papers and submissions, followed by reports and other publications from Australian organisations and governments. The Medical Journal of Australia was the most cited journal, with 392 references to its articles (11.8% of all journal articles cited) in discussion papers, commissioned papers, submissions and an interim report, and 58 references to its articles (13.7% of total journal articles) in the three final reports. Our findings demonstrate the importance of credible, local, accessible, peer-reviewed evidence in reforming the national health system, including hospitals, primary health care and preventive health care.

Elizabeth C Kalucy BSc, MSc, Dip Ed · Eleanor M Jackson Bowers BA(Soc Sci), MNurs, GradDipInfoStud

Objective: To determine changes in the pattern of use of standard general practice consultations, and the degree to which any changes are offset by the use of special Medicare Benefits Schedule (MBS) items.Design, participants and setting: Population-based retrospective analysis of age- and sex-standardised Medicare claims data (1994–2009) on the utilisation of general practice standard consultations (Levels A, B, C and D) alone and in combination with health assessments and care plans and other special MBS items.Results: Utilisation rates of Level C and D (long) consultations increased consistently from 1994 to 2004, but by 2009 a considerable decline had occurred. A reverse of this pattern was observed for Level A (short) consultations. When utilisation rates for special items and long consultations were combined, the combined utilisation rate followed an upward trend until 2007, but also declined in 2008 and 2009.Conclusions: The decline in the use of Level C and D consultations in recent years has been dramatic and accompanied by an increase in use of Level A consultations. While the use of special items has offset the decline in long consultations, this compensating effect has weakened in the past 2 years. This pattern is at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management. Given the current situation, the recently introduced Medicare reforms (May 2010), including changes to Levels B, C and D consultation item descriptors, may not be sufficient to change consultation patterns.

Michael J Taylor BPharm(Hons), LLB(Hons), PhD · Dell Horey BAppSc(Chem), MMedSc(Clin Epi), PhD · Charles Livingstone BA, MEc, PhD · Hal Swerissen BA(Hons), GradDipPsych, MAppPsych

Delegation to practice nurses may be the main reason for an increase in Level A consultations In their analysis of Medicare claims data for general practice consultations published in this issue of the Journal, Taylor and colleagues report a recent decline in Level C and D (long) consultations and an increase in Level A (short) consultations — a pattern they consider to be “at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management”.1 They hypothesise that the increased use of Level A consultations may reflect: the administrative burden created by the complexity of Medicare Benefits Schedule (MBS) special items; an increase in encounters for “vaccinations, prescriptions, medical certificates or test results”; or greater use of practice nurses.1 Data from the BEACH (Bettering the Evaluation and Care of Health) program2 suggest that the third option — greater use of practice nurses — explains most of the increase in claims for short (Level A) consultations. The introduction of MBS items for practice nurses in May 20043,4 had a significant impact on the use of Level A consultations. Trends in utilisation of short consultations can be followed in BEACH data, with the lowest proportional use occurring in April 2004 to March 2006, when 1.0% of all claimable consultations (Medicare or the Department of Veterans’ Affairs [DVA]) were short consultations. By 2008–09, short consultations accounted for 1.5% of all consultations.5 However, the mean duration of measured consultations (claimable from Medicare or the DVA) did not change over this period (average, 15 minutes; median, 13 minutes).5 This suggests that the increase in shorter-duration consultations has been offset by an increase in longer-duration consultations. Short consultations in 2008–09 included a large number of procedures, and practice nurses were involved in 24% of these consultations, a much greater proportion than the average for all consultations (6.4%).2 This led us to compare consultations for 2008–09 with those for 2003–04,6 just before the introduction of MBS items for practice nurses. In both years, short consultations were relatively straightforward, involving, on average, 1.2 patient reasons for the encounter (fewer than the average for all consultations of 1.5–1.6 reasons) and management of fewer problems (single-problem consultations represented 89% of consultations in 2003–04 and 87% in 2008–09). However, in 2003–04, 26% of the problems managed were chronic conditions, while in 2008–09 this proportion had increased to 36%. Prescriptions, referrals and counselling were provided at low levels in both 2003–04 and 2008–09. However, procedures increased 3.4-fold, from 112 per 1000 short consultations in 2003–04 to 385 per 1000 in 2008–09 when practice nurses undertook almost two-thirds of all recorded procedures. More specifically, there was a fourfold increase in the categories “dressings” (from 20 to 78 per 1000 short consultations) and “excisions” (commonly cauterisation) (7 to 26 per 1000 short consultations), and a threefold increase in “incisions” (venesection and ear syringing being the most common) (5 to 14 per 1000 short consultations). There was no point-of-care INR (international normalised ratio) testing in 2003–04 but, in 2008–09, 31 INR tests were conducted per 1000 short consultations. Further, the number of vaccinations administered doubled, from 105 to 214 per 1000 short consultations. As regards administrative activities, these almost doubled between 2003–04 and 2008–09, from 19 to 35 per 1000 short consultations; in both years, almost half were for sickness certificates. Other administrative procedures recorded, including those related to health care plans, increased from 10 to 17 per 1000 short consultations. These BEACH study results show an increase of about 45% in claims for short consultations between 2003–04 and 2008–09. Two-thirds of these claims are accounted for by increases in vaccinations (23% of the increase), dressings (25%), INR tests (10%), and excisions (8%). Practice nurse involvement in procedural care accounts for about three-quarters of the increase in short consultations. By contrast, the rise in administrative activities accounted for only 5%–6% of the total. Taylor and colleagues suggest that their findings of an observed rise in Level A consultations1 is directly contradicted by reports from the BEACH study of a decrease in the number of single-problem encounters.5 While this decrease is true for the average of all consultations, it does not apply to short consultations, which are, in the main, single-problem encounters. Finally, Taylor et al propose that the increase in Level A consultations1 means there is an increasing proportion of “obvious” and “straightforward” patient encounters, and this “may support targeted delegation of such consultations to nurse practitioners or physician assistants”.1 As we have shown, assistance from, and delegation to, practice nurses may already be the main reason for the recent increased use of Level A consultations, with administrative activities accounting for only a small proportion. The newly announced enhanced role for practice nurses in primary health care (the federal government’s 2010 Budget),7 planned to commence in 2012, may further influence GPs’ utilisation of short consultations.

Helena C Britt BA, PhD · Salma Fahridin BAppSc(HIM), MHSc · Graeme C Miller MB BS, PhD, FRACGP

To the Editor: A fundamental shift in the nature of general practice work and workplaces has occurred over the past decade and is gathering pace. Increasingly, general practitioners are performing, and being asked and funded to perform, more managerial and coordinating services, rather than merely providing clinical services. We are being placed into teams where practice nurses, mental health nurses, allied health providers and even students are contributing to the provision of services. What has led us to this change? A review of general practice reforms between 1989 and 2009 noted a decline in the autonomy of general practice and an increase in “processes initiated and managed by government with involvement of a broad range of medical and other groups”.1 The National Primary Health Care Strategy, first released in 2008, reflected some of these changes. It included incentives for GPs to practise quality preventive health care, and had an increased focus on multidisciplinary care from primary care teams. At the coalface, the financial implications of these initiatives have led to a change in workplace structure, with shifts from solo to group practice, from small group to larger group practice, and even to Super Clinics (a component of the National Primary Health Care Strategy) where team coordination is more feasible and practical. The administrative and information technology requirements of these new initiatives have made it increasingly difficult for smaller and more “traditional” individual practices to survive. The larger financial investment involved has led to an increased vulnerability to medical corporatisation and a steady decline in independent practices, especially those servicing populations with a non-English-speaking background. Also, a generation gap in general practice is emerging from this consolidation process, with older GPs — who were nurtured on the concept of general practice being limited to looking after your patients yourself and occasionally getting specialist advice and input — having trouble coming to terms with this shift. In contrast, registrars, junior doctors and even medical students are well used to the concept of team and coordinated care arrangements. So is this a good thing? Certainly, the increasing number of patients suffering from chronic disease will benefit from a broader based and more coordinated management approach. Also, financial rewards for managing complex conditions in a comprehensive and holistic fashion should be encouraged. However, there are dangers. The resulting increase in bureaucracy has already become evident and continues to alienate GPs. Small, independent practices are a dying breed, and the loss of much-needed experienced GPs, or at least the alienation of them from their communities, is something the nation’s health will lament.

James A Best

The GP Super Clinics Program is a highly topical and controversial initiative with varying levels of support within the policy, consumer and health care communities. Here, we describe the GP super clinic initiative of the University of Queensland (UQ), and how it aims to enhance primary-care capacity in the regions where clinics are based. The UQ GP super clinic model has considered the concerns of general practitioners, patients and other stakeholders, and addresses the needs of these groups while providing an excellent opportunity for the university to be involved in innovative service delivery, community-based education, primary-care service design and evaluation.

Jared M Dart BA, MB BS, PhD · Claire L Jackson MB BS, MPH, MD · Helen J Chenery MSpThy, PhD · Paul N Shaw BSc, PhD, FRPharmS · David Wilkinson MB ChB, PhD, DSc

The collaboratives approach to quality improvement has been popular with GPs and other practice staff The Australian Primary Care Collaboratives (APCC) program has shown that Australian general practices can improve processes and outcomes in the treatment of diabetes, secondary prevention of coronary heart disease, and access to care in practices with long waits. In the past, systems of general practice care have had an acute care bias, which has hampered patients with chronic illness in managing their conditions effectively. There is a mismatch between the needs of patients with chronic conditions and the capacity of our primary care delivery systems to meet those needs.1 Despite advances in Australian general practice, such as expanded roles for practice nurses, there is still no overall systematic approach to improving care for people with chronic disease through implementing evidence-based guidelines. The collaborative modelFor the past 5 years, the Australian Government Department of Health and Ageing has sponsored the APCC program. More than 1000 Australian general practices (12% of all practices) have participated. The program is based on the Institute for Healthcare Improvement’s “breakthrough collaborative” methodology,2 as modified by the National Primary Care Development Team in the United Kingdom. Large-scale system change in UK general practice resulted in a fourfold reduction in mortality from existing coronary heart disease and a 60% reduction in waiting times (determined by the number of days to the third next available appointment) in participating practices compared with other practices.3 In 2004, a team from Australia took part in an international training course in collaboratives run by the National Primary Care Collaborative in the UK. This was critical to the early successes of the Australian program, which showed that the same approach could apply to the Australian context.4 The APCC program is delivered by Improvement Foundation Australia, a not-for-profit organisation with expertise in quality improvement programs, including collaboratives. Organisations supporting the program include the Australian General Practice Network, the Royal Australian College of General Practitioners, the National Heart Foundation of Australia and Diabetes Australia. What is a collaborative?The aim of a collaborative is to improve health outcomes by closing the gap between best care and usual practice for a specific topic. Topics are the focus for quality improvement and can either be diseases (such as diabetes or chronic obstructive pulmonary disease) or care processes (such as improving access though improved care scheduling, or promoting self-management for chronic conditions). The expert reference panelEach topic has an expert reference panel that brings together experts in evidence application (those who have already achieved “breakthrough” results in their work) and quality improvement. The panel develops the aims of the collaborative, chooses a system of measurement, agrees to the change principles and collates change ideas that are known to achieve results. The agreed change principles for chronic disease topics are: build the practice team; establish a register of people with the chronic disease, as well as a process for validating and updating the register; be systematic and proactive in managing care; involve patients in developing and delivering care; and develop effective links with key local partners. These principles broadly incorporate the features of the “chronic care model” described by Wagner and colleagues.1 The workshopsParticipating practices send teams of clinicians and staff to three workshops, where they: hear from topic and quality improvement experts; listen to representatives of exemplar practices to learn what works; use dedicated team time to plan for action after the workshop; and share, debate and learn from each other. Between each workshop there is an action period, during which practice teams apply what they have learned. Practice teams learn the “model for improvement”5 and “plan, do, study, act” (PDSA) cycles.6 These small-scale tests of change can be challenging to incorporate into a busy work environment. The Improvement Foundation therefore provides trained facilitators to help practices in local general practice networks apply the tests to their daily work. The collaboratives approach to quality improvement has been popular with GPs and other practice staff. “Ownership” of the changes and their implementation details, tested through PDSA cycles, increase practice enthusiasm. Similarly, “measures” that improve over short periods of time encourage practices to achieve positive results. The measurementsTo monitor improvement, de-identified measures are collected monthly, usually directly from clinical software. Initial results are often surprising to practices and strongly motivate participants to improve their processes and levels of patient care. Examples of improved results for patients with diabetes from a 2009 wave in Victoria and Tasmania are shown in the Box. A “wave” is a singular collaborative, consisting of 20–200 practices that work together through an 18-month cycle of learning workshops, action periods and measurement. Practices in all state and nationally based waves (about 720) achieved similar improved outcomes for around 157 000 people with diabetes. By comparing outcomes at the end of a wave with those at the beginning, overall we found: 27 596 more people on diabetes registers with a recorded glycated haemoglobin (HbA1c) level ≤ 7%; 18 236 more people on diabetes registers with a recorded total cholesterol level < 4 mmol/L; and 22 578 more people on diabetes registers with a recorded blood pressure level ≤ 130/80 mmHg. The futureWe believe this approach to quality improvement can play a major role in improving the processes and experiences of care in general practice, primary care, and health care more broadly.7 It has been shown here and abroad that, with the right reach and policy levers, it is possible to effect large system change.3 It has also been argued that this is cost-effective.8 Early learnings from the APCC, including expanding the role of practice nurses, are now part of the existing service delivery system within general practice. The program has also identified other changes within collaborative practices, such as proactive and systematic care for patients with chronic disease, as suggested reforms that could be implemented through voluntary practice enrolment and expansion of team-based care. These policy initiatives, all elements of the chronic care model,1 support the collaboratives’ work and drive quality improvement at the practice level. In 2009, the Australian Government expanded the scope of the APCC program to include two new topic areas: chronic obstructive pulmonary disease and prevention of chronic disease (including self-management). The program has already achieved significant results and should be an ongoing part of the regionalised primary care focus of the reformed Australian health system. Improved outcomes for patients with diabetes:* APCC program — Wave 3 APCC = Australian Primary Care Collaboratives. HbA1c = glycated haemoglobin. * HbA1c, blood pressure and cholesterol level measurements performed within the previous 12 months.

Dale R Ford MB BS, FRACGP, FACRRM · Andrew W Knight MB BS, MMedSci(ClinEpid), FRACGP

Much of the rhetoric on interprofessional learning is not underpinned by high-level evidence Interprofessional education (IPE) has been identified as a critical component in the development of a collaborative, practice-ready health care workforce in Australia.1 According to the Centre for the Advancement of Interprofessional Education in the United Kingdom, IPE “occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care”.2 Its purpose is to improve patient outcomes by providing a learning environment that enables undergraduates (and postgraduates, where appropriate) to gain a better understanding of teamwork, and of how each discipline contributes to team-based care without losing its professional identity. It seems reasonable to assume that IPE is an effective way for professionals to learn how to work in teams. However, it is important to establish whether there is an evidence base that supports the link between IPE, improved interprofessional practice (IPP) and better patient outcomes. The World Health Organization’s Framework for action on interprofessional education and collaborative practice cites research evidence for the benefits of IPE to collaborative practice.3 These benefits include improved access to and coordination of health services, better use of specialist resources, and improved health outcomes for people with chronic disease. They also include improved patient care and safety, reduced patient complications and length of hospital stay, and reduced suicide rates in patients with mental illness. However, evidence for the link between IPE and improvements in collaborative care is tenuous. A Cochrane review of the impact of interprofessional collaboration on professional practice and health care outcomes found only five studies that met randomised controlled trial (RCT) inclusion criteria.4 While the review found that practice-based interprofessional collaboration interventions can improve health care processes and outcomes (eg, patient satisfaction and professional competence), its conclusions were limited by the small number of studies and sample sizes, and because many of the studies were confined to medicine and nursing. The review recommended the need for longitudinal, more rigorous, cluster-based RCTs.4 Advocacy for the introduction of IPE into medical, nursing and health science curricula around Australia is being driven by several factors. These include workforce shortages, concerns about patient safety, the need for team-based care to meet the growing burden of chronic disease associated with ageing, and the pressing need to improve shared care of patients with mental illness. Australia has lagged behind comparable countries in systematically introducing IPE and promoting IPP. There has been a lack of government policy initiatives to fund the development of such programs.5 In contrast, for more than a decade, Sweden has been conducting IPE in clinical environments by establishing hospital wards dedicated to interprofessional learning and practice. Students across medicine, nursing, physiotherapy, occupational therapy and social welfare have been collaboratively managing patients in orthopaedic and geriatric wards, under the supervision of a multidisciplinary team.6 Graduates have indicated increased confidence in working collaboratively following their interprofessional learning experiences.7 A recent Australian initiative is the Health Care Team Challenge, which brings together undergraduates from a range of disciplines to work in interdisciplinary teams to develop a management plan for a clinical case study scenario. The purpose of this program is to increase students’ exposure to, immersion in and mastery of interprofessional practice.8 However, there are barriers to introducing IPE in the clinical environment.9 The most significant are logistic difficulties with timetabling, student recruitment and finding suitable clinical environments such as wards or practices for conducting programs. Student-related barriers include balancing numbers from each discipline, role uncertainty and lack of relevant joint assessment tasks. Other challenges include recruitment, training and workload of staff; structural and policy issues (eg, curriculum development, joint accreditation and validation); and funding. Team-based care is essential to meeting Australia’s growing burden of chronic disease associated with ageing, and the burgeoning health problems of obesity, diabetes and mental health. The government is now encouraging and funding this need through a range of initiatives, particularly in general practice through the Enhanced Primary Care Program and the Better Access to Mental Health Care initiative. The current health care reform proposals place an emphasis on primary health care, and Health Workforce Australia identifies interprofessional learning as a way forward in promoting collaborative practice. The challenge is to ensure that this does not merely become a logistic exercise. It is clear that much successful health professional learning is based on the principle of “learning by doing”, and has occurred in the absence of RCT evidence establishing its efficacy and effectiveness. In this instance, it may prove fruitless and time-wasting to wait for sufficient evidence from RCTs before proceeding with IPE and IPP programs.

Leon Piterman MD, MMed, FRACGP · Jennifer M Newton EdD, BA(Hons), RN · Benedict J Canny BMedSc, MB BS, PhD

I like this book. Its starting point is a recognition of medicine as a true profession — that is, an activity which, being concerned with deeply personal problems, is aimed at serving people in a manner which enables them to act on their own. Its subject matter is the pursuit of this honourable goal in a world in which resources are finite, medical practice is increasingly undermined by corporatisation, accountability threatens to become an end in itself and the community expects that treatment will always be successful. Its achievement is an informative sketch of what a doctor needs to know and do, over and above the adequate knowledge and practice of medical science, if he or she is to live out the Hippocratic commitment to the “benefit of the sick” in 21st-century Australia. The authors are specialist practitioners in both the medical and the legal professions, so the book is ethically informed without focusing on questions of ethical theory. After a brief introduction to forms of ethical thinking and the qualities of good doctors, the authors explain the professional and regulatory standards that structure and constrain medical practice today. Clarity is one of the authors’ virtues. They explain in advance which issues will be covered by their discussions and which won’t. Chapter 7, for instance, on negligence, professional liability and adverse events, aims to assist doctors to understand our current legal system for handling claims for damages and the closely associated system of professional medical indemnity (both of which have been the subject of considerable change in recent years). It describes a change in the notion of “negligent conduct” without debating the merits of the change. And in Chapter 19, on determining and certifying death and reporting deaths to the coroner, obligations deriving from the law in each jurisdiction are set out so as to reveal both common threads in the various laws and differences in detail between them. This book will truly be a useful and accessible guide for busy doctors. As I say, I like this book. (Reader, beware! I am one of many acknowledged in the credits.)

Bernadette M Tobin

Objective: To investigate whether the level of professional satisfaction of Australian general practitioners varies according to community size and location.Design, setting and participants: Cross-sectional, population-level national survey using results for a cohort of 3906 GPs (36% were “rural” participants) from the first wave of a longitudinal study of the Australian medical workforce, conducted between June and November 2008. Geographical differences in levels of professional satisfaction were examined using five community size categories: metropolitan, ≥ 1 million residents; regional centre, 50 000–999 999; medium–large rural, 10 000–49 999; small rural, 2500–9999; and very small rural, < 2500.Main outcome measures: Level of professional satisfaction expressed by GPs working in different sized communities with respect to various job aspects.Results: Professional satisfaction of GPs did not differ by community size for most aspects of the job. Overall satisfaction was high, at about 85% across all community sizes. Satisfaction with remuneration was slightly higher in smaller rural towns, even though the hours worked there were less predictable. Professional satisfaction with freedom of choosing work method, variety of work, working conditions, opportunities to use abilities, amount of responsibility, and colleagues was very high across all community sizes, while difficulties with arranging locums and the stress of running the practice were commonly reported by GPs in all community sizes.Conclusions: GPs working in different sized communities in Australia express similar levels of satisfaction with most professional aspects of their work.

Matthew R McGrail BSc(Hons), GradDipIT, PhD · John S Humphreys BA(Hons), DipEd, PhD · Anthony Scott BA, MSc, PhD · Catherine M Joyce BA(Hons), MPsych, PhD · Guyonne Kalb MEc, PhD

Australia’s general practitioners are working fewer hours, and many are leaving medical practice. Little is known about when and why experienced mid- and late-career GPs move away from clinical practice. Although career downsizing is often seen as an abrogation of vocation, it may reflect a desire to broaden work experiences within a constrained set of options. Policy should focus on supporting and enhancing the development of GPs’ careers. This approach should acknowledge that career trajectories for GPs are often relatively flat from mid career onwards, and that a GP’s working life extends beyond clinical work in one general practice.

Lesley M Piko MBA, FCPA, FAICD · Christine B Phillips MB BS, MA, FRACGP, Associate Professor

For effective preventive care, policies and programs are needed that provide incentives, address workforce roles, utilise information systems and empower patients With an ageing population, a stretched health budget, and mounting costs associated with increasing levels of chronic disease, prevention is a priority for all Australian governments. But how effectively is evidence-based preventive care currently being provided in general practice? Rates of cancer screening by general practitioners have improved dramatically,1 but there has been less progress in other aspects of preventive care — for example, fewer than 30% of patients at risk of chronic disease are routinely given advice about diet or physical activity, and only 10% are referred to other health care practitioners for interventions.2 Although some may consider behavioural interventions to be too time-consuming to justify their potential gain, there is evidence that they can be effective in general practice and make a significant contribution to population health.3 Of course, critical drivers to health exist in the social and physical environment, such as socioeconomic status and the availability of safe opportunities for physical activity, and thus preventive care for individuals must complement a population health approach to these problems. The National Primary Health Care Strategy calls for a more systematic approach to implementing preventive care,4 including provision of appropriate and targeted screening services, health checks for specific population groups and at critical stages of life, and preventive interventions consistent with evidence-based guidelines such as the Royal Australian College of General Practitioners (RACGP) Guidelines for preventive activities in general practice.5 The National Primary Health Care Strategy recognises the importance of population groups in greatest need receiving effective interventions. To achieve this, we need a multilevel approach to implementing preventive care, including structural aspects (ie, practice, workforce and financial considerations), contextual aspects (including patient considerations) and practitioner aspects (related to changing professional behaviour). Many of the preventive recommendations in the current reform documents are focused on the structural level, recognising that general practice and primary health care are currently not adequately supported or funded for population health approaches to risk reduction and management across local communities and populations.6 The recent rationalisation of preventive health care item numbers (which occurred on 1 May 2010), into four new time-based items (Box), has reduced their complexity, but they still do not provide support for preventive care throughout a person’s life, or facilitate involvement of the whole practice team in preventive care. There is a need to re-examine workforce roles and responsibilities to determine how the mix of primary health care professionals can best deliver preventive care. In the United Kingdom, for example, practice nurses play a key role in several areas of practice. They identify the patients most suitable for health checks, assess risk factors and combined risk scores (using algorithm tools), provide motivational counselling and health education, negotiate behavioural goals, provide opportunistic brief interventions and arrange referrals and follow-up recalls.8 Also important are information systems to support patient recalls and reminders for preventive health checks, to monitor patients for follow-up, and to audit records to determine population coverage and evaluate the impact of preventive care on risk and outcomes. Decision support systems for patients and providers can help assess risk and instigate guideline recommendations.9 The lack of a robust national framework for funding, prioritising, developing and implementing evidence-based guidelines remains a major stumbling block to effective primary care.10 Current guidelines are predominantly developed by non-government organisations with insufficient funding to support implementation. It is essential that we have appropriate measures and means to evaluate the quality and outcomes of preventive care in general practice. What little information is available suggests significant gaps between evidence-based preventive care guidelines and practice.11 Patients should not be considered passive elements in preventive care. Patient health literacy and engagement are directly correlated with uptake and effectiveness of preventive interventions in general practice.12,13 Developing, promoting and utilising self-assessment tools (including risk-assessment tools) may enhance delivery and uptake of evidence-based preventive care. When risk is personalised, patients gain a better understanding of their health, make more appropriate use of screening tests, and improve their perception of risk.14 A more robust evidence base is necessary to overcome professional and patient barriers to implementing evidence-based preventive health measures, such as lack of compliance with and adherence to lifestyle modification. A theoretical understanding of the processes involved in changing the behaviour of health care professionals enables interventions to be better targeted at barriers to practice change.15,16 For example, an understanding of the fit between practitioner behaviour change and current practice routines can help develop tailored roles for members of the practice team in preventive care. This, along with more rigorous design of interventions,17 may result in more successful implementation of evidence-based changes.18 So what could all this change mean in practice? In future, patients will undertake individualised risk assessment at critical points in their lives. GPs will offer evidence-based preventive interventions tailored to a patient’s level of risk. Practice nurses will facilitate assessments and coordinate access to health education and other interventions as appropriate. Practice systems will follow up at-risk patients and provide reminders and information to support evidence-based interventions. Local primary health care organisations will ensure availability of services to support preventive care at the local level, and deliver health promotion and preventive programs targeting risk factors they have identified using data analysis at the population level. As with all reforms, it is difficult to envisage how such changes can be achieved. Funding targeted at higher-risk groups and people in most need, support for new roles for practice staff, and support from the soon-to-be-established regional primary health care organisations (“Medicare locals”) in providing access to support services and allied health providers, as outlined in the Primary Health Care Strategy, would be a good start. New Medicare preventive health care items7 Time-based health assessment items: brief assessment: < 30 minutes duration ($55.00) standard assessment: 30–45 minutes ($127.80) long assessment: 45–60 minutes ($176.30) prolonged assessment: > 60 minutes ($249.10) Available once only, assessments for: children aged 3–5 years (Healthy Kids Check) patients aged 45–49 years at risk of chronic disease refugees and other humanitarian entrants Available once every 9 months, assessments for: Aboriginal and Torres Strait Islander patients Available annually, assessments for: patients aged 75 years and older permanent residents of residential aged-care facilities patients with an intellectual disability Available once every 3 years, assessments for: patients aged 40–49 years at high risk of diabetes

Danielle Mazza MD, FRACGP, DRANZCOG · Mark F Harris MD, MB BS, FRACGP

Nursing in general practice has seen a recent dramatic expansion in funding and participation. Similar to general practice itself, before the introduction of vocational training, nurse practitioners come from a variety of professional backgrounds with differing skill bases. This has led in both cases to a shift towards greater regulation and standardisation. To underpin this standardisation, comprehensive, well respected reference resources, such as the seminal General practice by John Murtagh, are required. For general practice nursing, such a reference should not only contain clinical guidance, but also address the many and varied needs of nurses in primary care. Areas such as administration and finance, professional development, leadership and teamwork, education and research need to be addressed. With respect to clinical guidance, the nurse in general practice has different requirements to both general nursing and general medical practice. Areas where this is more apparent include triaging, vaccination, medication storage and management, infection control, wound management and health promotion. The recently released General practice nursing is written by two leading Australian nursing educators and two leading Australian general practice educators, and has 29 contributing authors. The ambitious scope of the book is to tick all of the boxes mentioned above, and it does so comprehensively and authoritatively. This well timed and much needed publication is written in a style and format that is accessible to its target audience of busy practice nurses. There are colour-coded chapters, tables, images and photographs that make it visually appealing and accessible. It also includes chapter overviews, objectives, case studies, testimonials, key messages, resource guides and links, and comprehensive referencing. General practice nursing is a new and important book for a rapidly expanding profession and, appropriately priced, it should become the definitive reference resource for nursing in Australian general practice.

James A Best · Sylvia M Lavis

To the Editor: General practitioners increasingly find themselves facing lawsuits for delay in diagnosis. Having personally been asked to be an expert witness in a number of cases, I have perceived a common theme. The cases generally turn on whether a particular investigation such as a computed tomography (CT) scan should have been ordered, based on the clinical presentation. Even when the doctor “wins”, this hardly compensates for the years of stress defending the case. As more cases are reported, more GPs are inclined to order tests to exclude rare conditions. No one has yet been successfully sued for ordering an “unnecessary” test. The public has been conditioned to regard tests as good and more tests as better. The public has also been conditioned to believe that tests are an entitlement. From the other side, a recent report by the Professional Services Review (PSR)1 gained media attention for focusing on the “unnecessary” ordering of CT scans. Radiation exposure in these tests is a potential health risk, and their use has increased greatly over the past 20 years. PSR Director Tony Webber was “alarmed at the number of these scans ordered without clinical justification”.1 It was subsequently reported that there was a drop in the number of scans ordered in the weeks after the report’s release.2 To order tests to satisfy the requirements of Medicare, there needs to be what the Health Insurance Commission regards as “clinical justification”. Yet to not order tests, when clinically there may be no strong grounds other than the exclusion of a rare condition, can lead a GP to face either a lawsuit or a medical board inquiry if a diagnosis is missed. And herein lies the problem. Clinical grounds are subjective and assessed in real-time, rather than with the benefit of hindsight after hours of poring over every tiny facet of a consultation. However, there are solutions. Medical boards need to give more weight to clinical judgement than to the ordering of tests. The medical profession needs to admit publicly that, despite 21st century science, the practice of medicine remains imprecise and not everyone can get a perfect outcome every time. Alternatively, if GPs are to be the protectors of the Medicare dollar and must risk facing legal action to do so, then perhaps Medicare needs to pay the indemnity insurance for those who put their neck on the line when they decline to order tests that the public believes are its entitlement.

Joe M Kosterich

Objective: To determine whether spirometry with regular medical review improves the quality of life or other health outcomes among patients with asthma or chronic obstructive pulmonary disease (COPD) managed in general practice.Design, setting and participants: Cluster randomised controlled trial conducted in 31 general practices in Melbourne during 2007–2008. Practices recruited 305 adult patients who had been prescribed inhaled medication in the preceding 6 months.Intervention: Practices were randomly assigned to one of three groups: Group A patients received 3-monthly spirometry performed by a respiratory scientist with results returned to the practice and regular medical review; Group B patients received spirometry only before and after the trial; and Group C patients received usual care.Main outcome measures: Quality of life, assessed with the 36-item Short Form (SF-36) Australian (English) Version 2 questionnaire at baseline and 3, 6, 9 and 12 months. Secondary outcomes were assessed with the European Community Respiratory Health Survey at baseline and 12 months.Results: The trial was completed by 253 participants: 79 in Group A, 104 in Group B, and 70 in Group C. Median age was 58 years (range, 18–70 years), and 167 participants (66%) were women. There were no significant changes in SF-36 Physical and Mental Component Summary scores from baseline to 12 months, or significant differences between groups on either scale or any subscale of the SF-36. There were also no significant differences in respiratory symptoms, asthma attacks, written asthma action plans, days lost from usual activities or health care utilisation.Conclusion: Three-monthly spirometry and regular medical reviews by general practitioners are not associated with any significant improvement in quality of life or other health outcomes for patients with asthma and/or COPD.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12606000378527.

Michael J Abramson MB BS, PhD, FRACP · Rosa L Schattner BEc, MPH · Nabil D Sulaiman MB ChB, FFPHM, PhD · Kate E Birch BSc(Hons) · Pam P Simpson BSc(Hons) · Eleonora A Del Colle BAppSc · Rosalie A Aroni BA(Hons), PhD · Rory Wolfe BSc, PhD · Francis C K Thien MB BS, FRACP, MD

Objectives: To assess whether the management rate of herpes zoster (HZ) in Australian general practice has changed since varicella vaccines became available; and to ascertain the mean age of patients attending general practice for HZ management, to assist with planning of vaccination to prevent HZ in older Australians.Design, setting and participants: Retrospective analysis of data for the period April 1998 to March 2009 on 1 078 671 (weighted) management encounters with consecutive patients of 10 885 general practitioners who participated in the BEACH (Bettering the Evaluation and Care of Health) national cross-sectional survey.Main outcome measures: Number of encounters for management of HZ (shingles) and of varicella (chickenpox); age of patients presenting for HZ management.Results: Regression analysis indicated a significant rise in the HZ management rate over the study period, with an average annual increase of 0.05 per 1000 encounters (P < 0.01). The management rate for varicella decreased significantly from 2.01 per 1000 encounters in 1998–1999 to 0.58 per 1000 in 2008–2009. Mean age calculated for each year of the study varied between 10.2 and 15.3 years for patients with varicella, and between 57.5 and 64.1 years for patients with HZ.Conclusions: There has been a significant rise in the HZ management rate and a decrease in the varicella management rate in Australian general practice over the period 1998–2009. Introduction of vaccination for HZ prevention at age 60 years should be considered, although addition of this vaccination to the existing schedule for vaccination at age 65 years is also likely to be beneficial and may be more pragmatic.

Mark R Nelson FRACGP, FAFPHM, PhD · Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHlth

Objective: To determine whether rates of pathology test ordering by general practitioners in general practices co-located with pathology collection centres (PCCs) are higher than those of GPs in practices located apart from PCCs.Design, setting and participants: We identified all practices in the Melbourne and Sydney metropolitan areas that were co-located with PCCs (same or immediately adjacent suite) and the date co-location was established. This information was merged with the Bettering the Evaluation and Care of Health database to identify samples of GP–patient encounters in co-located practices (n = 31 700) and practices located apart from the nearest PCC (n = 289 700) over the period 2000–2009. Using Poisson regression analysis and logistic regression analysis, we compared GP test-ordering rates across the two types of practices, controlling for a range of potential confounders.Main outcome measures: Numbers of tests ordered per encounter; likelihood of ordering one or more tests per encounter.Results: In unadjusted analyses, GPs in co-located practices ordered more pathology tests than GPs in practices located apart from PCCs (40.3 v 37.0 tests per 100 encounters, P = 0.01) and had a higher likelihood of ordering one or more tests (16.8% v 15.5% of encounters, P < 0.01). After adjusting for other predictors of test ordering, however, neither test-ordering rate (rate ratio, 0.98; 95% CI, 0.93–1.05; P = 0.56) nor likelihood of ordering one or more tests per encounter (odds ratio, 1.01; 95% CI, 0.95–1.07; P = 0.79) differed significantly by co-location status. Sub-analyses within specific test groups and types showed few systematic differences.Conclusions: Pathology test-ordering rates are not higher in practices co-located with PCCs. To the extent inappropriate commercial influences and relationships exist in the pathology sector, GPs’ test-ordering behaviour may be unaffected.

David M Studdert LLB, ScD, MPH · Helena C Britt PhD · Ying Pan BMed, MCH · Salma Fahridin BAppSc(HIM), MHSc(CDM) · Clare F Bayram BAppSc(HIM)(Hons) · Lyle C Gurrin PhD

Genomic research can link specific molecular genetic information with specific diseases. Implications of genomic medicine in general practice include developments in screening and diagnosis, predicting disease prognosis, and optimising preventive and therapeutic care. As users or co-producers of genomic information, or as collaborators in genomic research, general practitioners can help realise the potential of advances in genomic research.

Frank M Sullivan PhD, FRCP, FRCGP · Pauline M Lockhart MB ChB, MRCGP, MPH · Timothy P Usherwood MD, FRACGP, FRCP

Only a quarter of patients’ deaths are due to cancer, but the vast majority of the patients of specialist palliative care services have cancer as a primary diagnosis. Almost two-thirds of patients dying of an expected illness do not receive specialist palliative care at all, and this proportion is likely to increase as the population ages. Australian health system care for dying people needs systematic change so that people who may require palliative care in the foreseeable future are systematically identified, and have proactive care plans developed to meet their complex needs. This can be done in general practice and aged care, as shown by a model for such care in the United Kingdom. We explain the need for system change, and propose steps by which this might be achieved.

Geoffrey K Mitchell PhD, FRACGP, FAChPM · Claire E Johnson PhD, RN, CM · Keri Thomas MB BS, MRCGP, MSC(PallMed) · Scott A Murray MD, FRCGP, FRCP(Ed)

To the Editor: As a long-time resident of the “swamp of uncertainty” which is general practice — where specialists dare not go — I am accustomed to receiving guidelines and consensus statements from esteemed colleagues and friends who have taken to studying some specific part of the human condition. But these statements inevitably involve primary care, where general practitioners try to achieve balance. Balance is hard to achieve. The “gastro-partialist” thinks that everyone should be on a proton-pump inhibitor. On the other hand, the “osteo-partialist” thinks no-one should be on a proton-pump inhibitor because they stop calcium absorption and double the risk of hip fracture after 10 years. I could go on. However, here I wish to comment on Heeley and colleagues’ article on the perception and management of cardiovascular disease (CVD) risk in Australian primary care.1 Two of the authors are paid by Servier — the company which provided GPs with free automated blood pressure-measuring machines (ABPMs). A review in the American Journal of Cardiology concluded that no ABPMs were accurate enough to be recommended for replacing a manual sphygmomanometer,2 particularly in older people, in whom vessel stiffness leads to overestimation.3 In the study by Heeley et al, ABPMs were used by 90% of the GPs. Australia’s Therapeutic guidelines: cardiovascular say that the blood pressure treatment target should be 140/90 mmHg for all patients.4 It quotes the Cochrane review, which states: A sensitivity analysis in diabetic patients and in patients with chronic renal disease ... did not show a reduction in ... mortality and morbidity outcomes with lower targets as compared to standard targets.5 Heeley et al have used other guidelines. Based on the data provided by Heeley et al, about 17% of the patients in their study were aged over 75 years. Risk calculators do not usually go beyond 74 years, but it appears that with all risk factors at optimum levels, a 75-year-old man still has greater than 15% 5-year risk of a cardiovascular event (ie, a high risk). Being 75 years old is risky! Trying to treat a 75-year-old man’s blood pressure is particularly risky because evidence suggests that there is a paradoxical increase in cardiovascular mortality in men aged over 75 years whose blood pressure is lowered by treatment.6 Heeley and colleagues also stated that “two thirds of patients at high risk of a first CVD event were not prescribed a combination of a [blood pressure]-lowering medication and a statin”. Considering the 17% of patients who were older than 75 years, although the PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) trial showed a reduction in cardiovascular mortality within this age group, there was no reduction in overall mortality.7 So why would a GP treat such patients when overall mortality is not reduced? I imagine that some GPs undertreat because they anticipate poor compliance, because uncorrectable factors are so great that pharmacological interventions will have a miniscule effect, or because the side effects of drug doses needed to achieve guideline targets will be problematic. Maybe they also feel that their ABPMs read a bit high! Balance is an unconscious compromise between real evidence and what is achievable. We need to consider the whole as well as the part if guidelines are to be clinically relevant.

Peter J Radford

How my uncle broke his back A Lower East Side city boy, son of a Jewish haberdasher, Depression years in the Smokies — a job with the CCC offered by a government man — he saw another America, set his sights on being a country doc, went to City College at night, Edinburgh for medicine — came home with a brogue, a pipe, a taste for haggis. The only doc in a town so small his name on a letter all that was needed, he spent his summers in a Finger Lake cabin, a Snipe moored nearby, whiling away his placid days sailing or sitting on his dock watching clouds build over rolling hills. Then once, to answer an emergency call, he ran barefoot, bathing suit wet, to his old Chevy, tore down the road, tires kicking up dust, heading for town. But a snapping turtle placed by his son in the car took a bite of his toe! He swatted and swerved, drove into a ditch — never made it to the old man collapsed in town.

Richard Bronson

In reply: We thank Radford for his insightful comments, seasoned with spice from the frontline of primary care. Although guidelines are an accepted part of clinical practice, they are just recommendations and are not without their limitations. Treatments need to be individually tailored according to many factors. Our aim, therefore, was to provide a current snapshot of adherence to cardiovascular guidelines in primary care in Australia.1 It would be naive of us to think that there would be complete adherence to the guidelines in the “real world”. We wished to obtain an overall benchmark figure and, more importantly, identify treatment gaps or disparities in care across important patient subgroups defined by risk of cardiovascular event. We recognise that digital blood pressure (BP) monitors are no better than mercury sphygmomanometers and require frequent (6-monthly) calibration. However, BP measurement technique is a far more important issue. The use of digital BP monitors in our study provided a standardised measurement machine, but we had no influence on their use or on BP measurement technique. Radford makes a good point regarding the absence of direct randomised trial evidence for the benefit of more intensive BP lowering. The BP target of less than 140/90 mmHg in individuals who are at high risk of a cardiovascular event, such as those with diabetes or chronic renal failure, is a sensible extrapolation from consistent observational epidemiological data. There is, however, convincing evidence of the benefits of multifactorial cardiovascular risk intervention among individuals at high risk.2 We also believe that the available data from randomised trials3,4 provide support for the efficacy of lowering BP in the elderly, and are more robust than the observational data cited by Radford. Similarly, systematic analysis of randomised trials of statin therapy supports efficacy of treatment in older patients.5 Despite their limitations, we believe that current evidence-based recommendations regarding preventive therapies are appropriate guidelines for managing patients who are at risk of a cardiovascular event. As with any guidance for clinical decision making, the application of these recommendations needs to take into account individual patient characteristics and circumstances. Finally, we believe that Servier’s support for this study demonstrates a successful academia–industry partnership. The academic partners had full control of the study design, analyses and publications.

Emma L Heeley · Craig S Anderson · Anushka A Patel · Alan Cass · David P Peiris · John P Chalmers

Charles Bridges-Webb was born on 15 October 1934 in Castlemaine, Victoria. A country doctor’s son, he graduated from the University of Melbourne in 1957 and went on to become an international figure in general practice research. Charles commenced his research, which he called “organised curiosity”,1 while a rural general practitioner in Traralgon, in south-eastern Victoria. He was appointed foundation Professor of Community Medicine (later renamed General Practice) at the University of Sydney in 1975, and was Head of Department until his retirement in 1994. Charles was a member of the Royal Australian College of General Practitioners (RACGP) Research Committee for 20 years and an RACGP representative on the National Health and Medical Research Council. He was an inaugural member of the Australian Association of Academic General Practice and its president from 1989 to 1991. Charles was an international leader in the development of morbidity surveys, and his publication on morbidity in general practice2 is one of the most important research publications from Australian general practice, offering an understanding of health and disease in the community. As member (1972–1998) and Chair (1991–1998) of the International Classification Committee of the World Organization of Family Doctors, Charles was a key developer of the International Classification of Primary Care, now the official World Health Organization classification system for primary care. In retirement, Charles was Director of the RACGP research unit and Chair of the Australian General Practice Statistics and Classification Centre (home of the BEACH [Bettering the Evaluation and Care of Health] program). He also spent time enjoying his extensive garden, working as a lay preacher and writing his autobiography.3 In 2002, Charles was made an Officer of the Order of Australia for services to primary health care research and general practice. A quiet, philosophical man, Charles saw the good in everyone and encouraged their strengths. He was notable for his generosity in sharing his talents and time, especially with young researchers, for his loving partnership with his wife Anne, and his ability to balance his extraordinary professional contributions with family life. Charles died in Sydney on 16 June 2010 and is survived by Anne and his four children, Andrew, Ian, David and Kate.

Michael R Kidd · Helena C Britt · Graeme C Miller · Deborah C Saltman