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Meeting local complex health needs by building the capacity of general practice: the University of Queensland GP super clinic model

Jared M Dart, Claire L Jackson, Helen J Chenery, Paul N Shaw and David Wilkinson
Med J Aust 2010; 193 (2): 86-89.
Published online: 19 July 2010

The GP Super Clinics Program is a federally funded program that uses an independent, competitive invitation-to-apply process to select preferred candidates based on which proposal best meets the local health needs and the objectives outlined in the GP Super Clinics Program Invitation to Apply.1 Some of these include: “well integrated multidisciplinary patient centred care”, “support for preventive care”, “high quality best practice care” and “efficient and effective use of Information Technology”.1

GP Super Clinics Program funding can be used for capital development, and up to 12.5% of the total funding can be used for recurrent expenses such as employing staff, but only in the first 4 years.

The University of Queensland (UQ) has received funding of $2.5 million to develop a GP super clinic on the UQ campus at Ipswich, and $7.5 million to develop a hub-and-spoke type of GP super clinic on Brisbane’s Southside. The Brisbane Southside super clinic will have two hubs: one at the Pharmacy Australia Centre of Excellence in the Brisbane suburb of Annerley, and a larger hub further south in Logan. There will also be a number of spokes — initially at Inala and Jimboomba. UQ is also the education and research partner for the GP super clinic at Redcliffe.

Stakeholder analysis

As part of the proposal-development process, UQ analysed relevant population health statistics and consulted with local stakeholders like general practitioners, Divisions of General Practice, the Royal Australian College of General Practitioners (RACGP), Queensland Health services and other peak bodies (eg, Diabetes Australia Queensland).

Local population health statistics (Box 1, Box 2) were used to determine appropriate geographical locations, local health issues and local use of the Medicare Benefits Schedule.2-4 Together, these rapid qualitative and quantitative approaches identified the following problems:

  • a high burden of prevalent chronic disease; and

  • a workforce deficit, and underuse of available Medicare items for screening, assessment and planning.

Qualitative data obtained during stakeholder interviews are summarised below.

“Not just another clinic”

GPs were concerned that the federal government’s super clinic funding would unfairly advantage a competing general practice, and there was strong opposition to the super clinic being “just another general practice clinic”.

Many GPs were concerned that the “specialisation” of medicine has limited the scope of practice for GPs, thereby limiting their professional and personal satisfaction with their work, and limiting patients’ access to necessary services. There was a perceived lack of recognition for general practice and of “de-skilling of GPs”. The important role of the GP as a generalist manager of complex comorbid diseases was also prominent in stakeholder feedback.

Education and training

There was broad consensus that GP super clinics should be involved in education and training, and should facilitate local GPs’ involvement in training medical students, prevocational trainees and general practice registrars. This raised a number of issues, in particular: the need for senior GPs to be involved in training in the super clinic; support for the involvement of the general practice regional training provider (RTP) in the super clinic’s training approach; and the need for an ongoing dialogue between RTPs, colleges (RACGP and the Australian College of Rural and Remote Medicine), General Practice Education and Training and UQ about how general practice training could be facilitated in the super clinic.

A need to support multidisciplinary care

Patients with chronic disease and complex health issues can benefit greatly from multidisciplinary care. Local GPs suggested it was difficult to adopt multidisciplinary management of patients with complex health problems or chronic diseases, in part because of a lack of allied health services. In general, GPs felt that facilitating GP coordination of multidisciplinary care would be a valuable contribution to the welfare of patients with complex health problems, society and the health system as a whole.

Impediments to GPs fulfilling this role were attributed to: the current structure of the Medicare Benefits Schedule, which discourages longer consultations and does not adequately support allied health services; lack of time to devote to patients with complex problems; lack of experience and expertise in specialist areas of medicine (eg, complex paediatrics, mental health, complex chronic disease in adults, dermatology, and lifestyle medicine); lack of awareness of local services and programs; lack of feedback from and integration of local allied health services; and cross-referral and fragmented care between specialists, patients’ “usual” GP and other GPs.

The University of Queensland GP super clinic initiative

UQ’s involvement in the GP Super Clinics Program is a perfect demonstration of its commitment to engagement, learning and discovery. By developing GP super clinics that meet pressing local health needs, UQ is engaging with the community, health professionals, and government and non-government organisations. Super clinics also provide an ideal opportunity to model successful interprofessional practice and provide interprofessional education. The two super clinics located on UQ campuses (Pharmacy Australia Centre of Excellence and UQ Ipswich) will be fully integrated into the health programs operated by UQ’s Faculty of Health Sciences. Likewise, super clinics offer a rich research environment in areas such as health-service design, health economics, e-health, social and behavioural aspects of health, and interprofessional practice.

To guide our involvement in the GP Super Clinics Program, we have developed a set of key objectives (Box 3).

Governance and business model

The diagram in Box 4 outlines the governance structure for the UQ GP super clinics. In short, there are local reference groups, a broad university-funded steering committee, and a university-funded super clinic advisory group that informs clinical, educational and research initiatives. UQ has also funded a 0.6 full-time-equivalent position of Director of GP Super Clinics to facilitate the development of the program. The clinics will operate on a mixed-billing business model, with GPs remunerated on a percentage of billing, not by salaries.

Advanced care hubs — collaboration with local providers

Our clinical-service and business models focus on enhancing the capacity of local general practices. Data show that most patients are highly satisfied with their “usual GP”.5 However, GPs often need to rely on other specialist medical and non-medical staff to facilitate optimal care for their patients. Likewise, many GPs develop specialised skills in an area of interest — so-called GPs with special interests or GPs with advanced skills. Within multidoctor practices, GPs occasionally refer patients to their colleagues who have additional skills in a particular area (eg, mental health, skin cancer medicine, women’s health). In ideal scenarios, these GPs would be supported by specialist colleagues who provide advice and patient consultations as required. This practice occurs, often, on an informal basis.

Inala Primary Care, one of the Brisbane Southside spokes, operates a complex diabetes service for the surrounding area. In this model, GPs who have undertaken advanced diabetes care training through the UQ Master of Medicine (General Practice) work as clinical fellows, and are supported by a multidisciplinary team and an endocrinologist. They provide appropriate and defined care for referred patients, working closely with the patient’s usual general practice team. Unpublished data show that patient outcomes are equivalent or superior to those of control patients treated at the outpatient service.

Our model, based in part on this experience, uses practice nurses, GPs with advanced skills, specialists and allied health professionals to manage patients with complex problems and to formalise this practice on a regional basis. Local GPs are encouraged to work sessions in their areas of special interest, and to develop locally appropriate clinical pathways based on available evidence and resources. These GPs will either hold, or be assisted to obtain, advanced qualifications in this area of special interest. This approach enhances the capacity of the local region, improves timely and appropriate access to specialised advice in an appropriate community-based location, addresses significant and emerging workforce pressures, and recognises the valuable role of “generalist” and “specialist” GPs in managing complex patient types. The model is illustrated in Box 5.

We are also fortunate to have a key partnership with Mater Health Services, which is the largest non-government provider of health services in south-east Queensland, and will provide specialist medical, nursing and allied health support in our Brisbane Southside super clinics.

Innovation centres for general practice

In Ipswich and Logan, UQ will operate small practices (with five to six full-time-equivalent GPs) focused on teaching and research, which will trial new technologies (particularly e-health), new systems and workforce roles. These practices will capitalise on the financial advantage provided by the federal capital funding to trial approaches that are relevant to everyday patient care and general practice, but that are currently not financially feasible in commercial or corporate general practice. Training of practice nurses, prevocational doctors and general practice registrars will be key priorities in these practices. The super clinics will also act as a local training site for formal and informal (eg, journal club) learning opportunities. UQ offers established Masters of Medicine programs in both general practice and primary care skin cancer medicine. We plan to explore appropriate advanced training and credentialling approaches with relevant stakeholders. Clinical data will be collected and analysed, and the findings will be integrated into ongoing quality improvement processes.

Extended-capability pharmacy — supporting effective and safe practice in primary care

Having hospital-based clinical pharmacists as part of a collaborative team has been shown to improve patient safety and appropriate prescribing.6 However, community-based pharmacist support for GPs has been lacking,7 with schemes such as the home medicines review program having been underused, perhaps as a result of a lack of access or awareness. Yet, our stakeholder feedback suggested that many GPs would value appropriate and timely advice from pharmacists, especially when managing patients with complex conditions. At UQ, we developed a model for an extended-capability pharmacy and sought commercial providers to commit to providing this service in our Ipswich, Logan and Annerley sites. The Annerley GP super clinic site, based in the Pharmacy Australia Centre of Excellence, is adjacent to the University’s School of Pharmacy. These pharmacies will be involved in collaborative advanced medication management programs for patients with chronic diseases.

Conclusion

There are a number of issues associated with the GP Super Clinics Program, and some resistance from the general practice sector has been reported in the media. However, we believe that our GP super clinic model has considered the concerns of GPs, patients and other stakeholders, and that it 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. We are currently constructing and refurbishing facilities before commencing operations in late 2010. Interested parties are encouraged to contact us via email at uqgpsupATuq@edu.au.

1 Indicators of health status in two University of Queensland GP super clinic localities compared with Queensland and with Australia as a whole2-4

No. per 1000 inhabitants or % (as shown)


Indicator

Ipswich

Logan

Queensland

Australia


Chronic disease risk factors

Obese men

186

190

163

146

Obese women

189

192

158

148

Smokers

280

271

262

248

Physically inactive

351

344

321

316

Chronic diseases

Musculoskeletal disease

354

343

341

362

Respiratory disease

335

331

321

311

Circulatory diseases

186

176

175

172

Mental and behavioural disorders

111

104

99

98

Type 2 diabetes

26

26

23

23

Avoidable complications

Avoidable deaths

72%

73%

73%

72%

Premature deaths (at < 75 years)

334

312

278

290

Deaths amenable to health care

30%

28%

29%

29%

Health status

Very high psychological stress

44

43

37

36

Fair or poor health

207

200

183

184

2 Access to and use of health care services in two University of Queensland GP super clinic localities compared with Australia as a whole

Ipswich

Logan

Australia


Residents per general practitioner

1709

1500

1403

Patients with chronic respiratory disease with a General Practitioner Management Plan*

11%

12%

15%

Patients with chronic musculoskeletal disease with a Team Care Arrangement*

7%

8%

10%

Eligible over-75-year-olds with an over-75-year-old assessment*

28%

26%

23%

Eligible 4-year-olds having a 4-year-old health check*

1%

12%

5%


* Estimated on the basis of Medicare,2 population and chronic disease prevalence data.3,4

3 University of Queensland GP super clinic objectives

  • Develop and assess the effectiveness of patient-centred, multidisciplinary clinical models for community management of patients who have chronic disease and/or risk factors for chronic disease. These models must:

    • Be financially sustainable;

    • Deliver quality, evidence-based chronic disease management services;

    • Empower patients to self-manage their chronic diseases.

  • Develop, trial and evaluate new health professional roles for primary health care, recognising the value of all health professionals and their particular skill sets.

  • Develop e-health solutions which enhance the capability of primary health care to:

    • Integrate patient care across the continuum of health services;

    • Enhance local health professionals’ capabilities to manage chronic disease;

    • Enhance patients’ capabilities to manage their own health care;

    • Evaluate the impact of chronic disease management strategies in terms of clinical outcomes, cost-benefit analysis and quality of life.

  • Develop vital and previously neglected community-based education opportunities for health professional students, which incorporate private health services (general practitioners and private hospitals) and provide vertical and horizontal integration of training opportunities.

  • Develop and implement community-based, primary health care research strategies focusing on the prevention and management of chronic diseases and associated lifestyle risk factors.

  • Share this knowledge through appropriate forums, and actively participate in the development of new models of primary health care.

4 Overview of the governance of University of Queensland GP super clinics


Note: The super clinic advisory committee and super clinic steering committee are funded by the University of Queensland. All other bodies shown are funded by the super clinic companies.

5 Proposed pathway for patients with complex conditions


GP = general practitioner. RN = registered nurse.

  • Jared M Dart1
  • Claire L Jackson2
  • Helen J Chenery3
  • Paul N Shaw4
  • David Wilkinson5

  • Faculty of Health Sciences, University of Queensland, Ipswich, QLD.

Correspondence: j.dart@uq.edu.au

Competing interests:

Jared Dart is the sole Director of iHealth Solutions Pty Ltd, which was contracted to develop the super clinic proposal for the Redcliffe Hospital Foundation (Redcliffe super clinic, August 2008) and the UQ (Ipswich and Brisbane Southside super clinics, January to June 2009).

  • 1. Australian Government Department of Health and Ageing. GP super clinics national program guide. Canberra: The Department, 2008. http://www.health.gov.au/internet/main/publishing.nsf/Content/pacd-gpsuperclincs-programguide (accessed Jun 2010).
  • 2. Medicare Australia. Statistics. Divisions of general practice statistics reports [database on the internet]. Canberra: Medicare Australia, 2009. https://www.medicareaustralia.gov.au/statistics/div_gen_prac.shtml (accessed Jun 2010).
  • 3. Population Health Information Development Unit. Population health profile for Divisions of General Practice: supplement. Report No. 74a. Adelaide: Public Health Information Development Unit, 2007; Mar.
  • 4. Population Health Information Development Unit. Population health profile for Divisions of General Practice. Report No. 74. Adelaide: Public Health Information Development Unit, 2005; Nov.
  • 5. Allan J, Schattner P, Stocks N, Ramsay E. Does patient satisfaction of general practice change over a decade? BMC Family Practice 2009; 10: 13.
  • 6. Nissen L. Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009; 66 Suppl 3: S29-S34.
  • 7. Ackerman E, Williams ID, Freeman C. Pharmacists in general practice — a proposed role in the multidisciplinary team. Aust Fam Physician 2010; 39: 163-164.

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