Global lessons for Australian general practice

We have much to share, but also much to learn, about providing truly universal health coverage

Ageing populations, overcrowded hospitals and emergency departments, increases in the numbers of people with chronic diseases and mental health concerns, consumer demands for improvements in health care services and access to new discoveries and technologies, struggling health budgets with a reduced focus on prevention and health promotion — these are just some of the global health challenges facing many countries, including Australia.

Yet, universal health coverage remains the greatest global health challenge. How do we ensure that all people have access to timely, acceptable and affordable health care of appropriate quality, making possible “the highest attainable standard of health as a fundamental right of every human being”, as enshrined in the constitution of the World Health Organization?1

In September 2015, the 193 member states of the United Nations General Assembly, including Australia, adopted Transforming our world: the 2030 agenda for sustainable development.2 This document outlines the 17 sustainable development goals (SDGs) that aim to end poverty and hunger, improve health and education for all people, and protect the global environment.3 Only one of these SDGs is specifically a health goal. It is to “ensure healthy lives and promote well-being for all at all ages”, and represents a call for universal health coverage.

This renewed global focus on universal health coverage is putting a spotlight on ways to reinforce the contribution that primary health care, and especially models of team-based general practice services, can make to strengthening health care systems in high-, middle- and low-income nations around the world.4

Australia has a strong model of universal health coverage through Medicare, the taxpayer-funded national health insurance scheme that subsidises access to general practice, other medical services and essential medicines, and augments the nation’s system of free public hospitals. However, there are gaps in Australia’s universal health coverage, and disparities in provision of health care services mean that some people miss out on equitable access to health care, including many Aboriginal and Torres Strait Islander people, people living in rural and remote areas with limited access to health care services, people with intellectual disability and mental health concerns, people who are refugees or seeking asylum, and people who are housebound and unable to get to our clinics at a time when home visits have become increasingly rare in many parts of our nation.5

There is also patchiness in the quality of the primary health care services available to some, especially older people, those with disability and those with complex chronic health care conditions. This is something that the Australian Government’s new Health Care Homes program seeks to tackle by having patients register with a single general practice.6 There has been advocacy for such a model of care for many years given the evidence that inadequacies in the prevention, early detection and management of chronic disease leads to an avoidable increase in the use of expensive hospital services.7 However, without support for increased community outreach and primary health care services delivered to homes and residential aged care facilities, especially for frail older people and those with disability, these reforms may not go far enough.

As President of the World Organization of Family Doctors (WONCA), I have had the privilege of examining primary health care models in many countries and to identify models of care that may provide solutions for Australia. Brazil, for example, has adopted a national model of Family Health Teams that provide coverage for the 200 000 000 people of that country, with a specific focus on meeting the challenges of access for people living in low-income housing and in rural and remote areas. Each general practitioner works in a team with nurses and community health workers, providing comprehensive clinic-based and home-based care to a population of around 4500 people. Each team is responsible for the care of every person living in a defined geographical area. Team members visit each household, document the health care needs of the residents, ensure that this care is provided, and report on the health status of their community, thereby contributing to population-based planning. A national network of 40 000 Family Health Teams ensures that nobody misses out on health care.8

Another example is Cuba, a small island nation of 11 million people with an enviable system of health care, based on strong primary care. Every person in Cuba has access to his or her own primary care doctor and nurse team. Again, each team is responsible for knowing the health status of all the people in their community, and provides clinic-based and home-based care for those who are older and frail or have a disability that prevents them visiting the clinic. This proactive outreach model ensures that all people, and especially the most vulnerable, have access to health care.9

Denmark ensures universal health coverage to its citizens through a health care system based on strong general practice. Each GP has a defined list of patients and is responsible for providing those people with primary health care services and coordinating any required referrals to other health services. All citizens are covered by the national insurance scheme and have free access to general practice services, regardless of their ability to pay. While general practices are privately owned, like in Australia, health care is entirely publicly funded with 75% of funding coming from fee-for-service and 25% from capitation payments. Each full-time GP provides care for around 1600 people, delivering about seven consultations each year for each citizen. Danish GPs face similar challenges to those of Australian GPs, with an ageing population with more people with complex comorbid chronic health concerns as well as expectations from government that they will provide increased preventive care activities without being given additional resources.10

Danish general practice is also a world leader in the use of electronic medical records. Danish GPs code each consultation, using the International Classification of Primary Care (ICPC), which allows GPs to analyse their own clinical activity to better understand the health needs of their patient populations, and also allows national aggregation of consultation data through the Danish General Practice Database.11 Primary care researchers can investigate the health status of the whole community, analyse the quality of care being delivered, provide comparative feedback to individual GPs about their own activity and make national recommendations for continuing improvements to health care services.

The fundamental importance of general practice research in Denmark and other nations provides additional important lessons for Australia. Several countries that are serious about ensuring the strength of their general practice services invest in primary care research that supports policy makers to make informed decisions about the allocation of resources and the planning of future services. Among the leading international models are the United Kingdom’s School for Primary Care Research, part of the publicly funded National Institute for Health Research. This School attracts annual government investment of 12.5 million pounds and involves eight of the nation’s leading academic general practice departments, which work together to conduct high quality health services research to support primary care development and train future primary health care research leaders.12 The Netherlands School of Primary Care Research is another global leader in this field, making major contributions to the global primary care evidence base.13

The Australian Government has recently made substantial reductions in investment in primary care research.14 It is to be hoped that the new Medical Research Future Fund, with its promise of a focus on research funding to improve health outcomes,15 will provide much needed resources to re-establish our own national institute for primary care research to lead the research needed to ensure that future primary health care investment decisions are based on sound evidence about community needs and effective interventions.

The education and training of the current and future primary care workforce is another critical component of ensuring strong general practice. Recent government reforms of family medicine in countries such as China, Indonesia and Vietnam are influencing a change in the pattern of the medical workforce in each of these nations, with a shift to formal postgraduate training of GPs. China, in particular, has embarked on postgraduate training for an additional 400 000 GPs over the coming 7 years.16

While successive Australian governments have recognised the need to train more medical graduates in the specialty of general practice and many other countries look to Australia as a source of inspiration in postgraduate GP training, the overall proportion of GPs to other specialists in Australia has been declining. The OECD reported in 2006 that the percentage of generalist doctors relative to other specialists in Australia had declined from 59.9% in 1990 to 51.9% in 2000.17 Using different methods, Health Workforce Australia reported that, in 2009, the percentage of GPs relative to other specialists and hospital-based non-specialists had declined to less than 45%.18 Given the benefits of a strong primary care workforce in providing cost-effective, equitable health care, can Australia afford to reduce the percentage of GPs further?

Australian general practice has much to share with the rest of the world about clinical care, research and education, but we also have much to learn that could further strengthen our own health care system to ensure true universal health coverage.