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

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.

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.

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 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.

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.

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.

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.