General medicine

Australian autism handbook. The essential resource guide for autism spectrum disorders. Benison O’Reilly, Seana Smith. Sydney: Jane Curry Publishing, 2008 (xv + 399 pp). ISBN 978 0 9804758 1 4. Autism is not as rare as we once thought. Recent Australian research indicates autism occurs in one child in 160, and half a million Australians are living in a family that has a child or adult with autism. The annual cost of autism spectrum disorders (ASDs) to the community is estimated at between $4.5 and $7 billion. It is an expensive disability for both the government and for families. For example, the cost of intensive applied behavioural analysis for a family is around $40 000 per annum, with a program in the preschool years lasting 2 to 4 years. While most of the literature on autism, especially for parents, is published in the United States or the United Kingdom and refers to American or British services, we now at last have an Australian guidebook for families. The authors are parents of children with ASD, and the book is primarily written for families of a newly diagnosed child. However, the Australian autism handbook will be invaluable for clinicians as a resource when talking to families and providing advice on services and resources. The text often refers to Australian research, and we need to recognise the degree and depth of Australian expertise and research on ASD. This book provides current information on services in each state or territory, the latest Medicare initiatives, and research areas of Australian specialists and academics. Clinicians will be interested in the perspectives and experiences of families (such as the susceptibility of parents of a child with autism to develop signs of depression), and to learn more about the latest treatments that parents have heard about and may request for their son or daughter with autism.

Tony Attwood

Objective: To investigate the long-term effectiveness of a general practice monitoring system with respiratory expert recommendations for general practitioners’ management of patients with chronic obstructive pulmonary disease (COPD), compared with usual care. Design, settings and participants: A multicentre randomised controlled trial of patients with COPD, clustered by general practices; 200 participants were recruited to maintain at least 75 participants per group for analysis. The trial took place from July 2005 to February 2008 in the south-western region of the Netherlands.Intervention: Ongoing half-yearly monitoring of COPD patients with respiratory expert recommendations for the GP was compared with usual care.Main outcome measures: Primary outcome — Chronic Respiratory Questionnaire (CRQ) score; secondary outcomes — CRQ domain scores, generic health-related quality of life (Short-Form 12 and EuroQol-5D), breathlessness (Modified Medical Research Council score), exacerbations, and decline in forced expiratory volume in 1 second. A detailed process evaluation was performed along with the trial.Results: Data from 170 participants were analysed. Based on repeated measurement analyses, the additional gain in CRQ score during follow-up was 0.004 points for monitoring compared with usual care (95% CI, − 0.172 to 0.180). Also, no important differences between monitoring and the usual care group were found for secondary outcomes. Half the monitoring visits resulted in disease management recommendations by a respiratory expert, and 46% of these recommendations were implemented by the GPs. Patient adherence to lifestyle recommendations was low.Conclusion: An expert-supported monitoring system for patients with COPD was not clinically effective. As patients had a pre-existing entry in the monitoring system, the population may be well regulated, with reduced room for improvement.Trial registration: www.clinicaltrials.gov NCT00542061.

Lisette van den Bemt MSc · Tjard R J Schermer PhD · Ivo J M Smeele MD, PhD · Leandra J M Boonman-de Winter MSc · Ton van Boxem MD, PhD · Joke Denis · Joke G Grootens-Stekelenburg · Richard P T M Grol PhD · Chris van Weel MD, FRCGP, FRACGP

Omission of funding details: In the In Clinical Practice article “Improving general practice consultations for older people with asthma: a cluster randomised control trial” in the 20 July 2009 issue of the Journal (Med J Aust 2009; 191: 113-117), funding details provided by the authors were inadvertently omitted. These details, which should have appeared in the acknowledgements, are as follows: This intervention study was funded by an Asthma Targeted Intervention Grant provided by the Australian Government Department of Health and Ageing; the Australian Government has not reviewed this material and does not represent or guarantee that its contents are correct. We also acknowledge the support of the Cooperative Research Centre for Asthma and Airways. The html and pdf versions of the article published online were corrected on 10 August 2009.

Dianne P Goeman · Lena A Sanci · Simon L Scharf · Michael Bailey · Robyn E O’Hehir · Christine R Jenkins · Jo A Douglass

Regardless of how obstructive lung disease is labelled, targeting treatment to components of the problem is the best solution Three-quarters of deaths due to asthma in Australia occur among people aged 55 years or older.1,2 Many more deaths and hospitalisations in older people are attributed to chronic obstructive pulmonary disease (COPD).2 Between 1997 and 2003, 318 deaths per year were attributed to asthma and 5581 deaths per year were attributed to COPD among Australians aged 55 and over.2 How can we do better than we are now in dealing with this problem? First, we need to consider whether we are dealing with two separate problems, or one, or several. This is the subject of some controversy. It has been argued for many years that the terms “asthma” and “COPD” are not particularly useful for clinicians in defining a disease or syndrome, particularly in older people.3 However, the terms are entrenched in clinical usage and, in the case of asthma, general usage. Furthermore, separate guidelines have been promulgated for both conditions. People who are labelled as having asthma have diverse clinical characteristics, and some people with other disease labels have clinical characteristics similar to those labelled as having asthma. There are very few features of aetiology, pathology, natural history, or management strategy that are uniquely linked to the diagnostic labels of asthma or COPD. Our view is that we are dealing with a diverse range of disorders that cannot be adequately classified simply as either “asthma” or “COPD”. The real problem we face is obstructive lung disease, whether it carries the label asthma, COPD, emphysema, or chronic bronchitis. Obstructive lung disease exists as a heterogeneous disorder affecting people of all ages. The manifestations of the disease may include episodic breathlessness (with or without cough) and progressively worsening exertional breathlessness and airflow limitation. In some individuals, this may progress to respiratory failure. Avoidance of smoking prevents one form of the disease, reduces the rate of lung function decline, and improves treatment response in more reversible disease. Rigorous attention to occupational hygiene in high-risk workplaces can prevent some cases of the disease. Reducing indoor exposure to smoke and fumes from biomass fuels may also prevent some forms of obstructive lung disease.4 However, no other preventive strategies are supported by available evidence. The range of management strategies that are available may control the disease, but do not cure it. In clinical practice, the various labels for obstructive lung disease tend to be applied in a fairly haphazard manner.5,6 This is not only because it is difficult to distinguish them clinically but also because there appears to be little point in doing so. Clinical management is most often guided by other characteristics. Among all patients with obstructive lung disease, management is targeted at person-centred problems: for example, pulmonary rehabilitation for breathlessness and loss of physical condition;7 bronchodilators for airflow obstruction and hyperinflation; inhaled corticosteroids for airway inflammation; smoking cessation for smokers; and influenza vaccinations for all those who are at risk of exacerbations. There is also increasing recognition of the need to assess and manage systemic problems and relevant comorbidities in older people with obstructive airway disease.8 In addition to addressing patients’ current problems, assessing their future risk is also important, and anticipation of exacerbations and deterioration will facilitate planning and better management. Targeting treatment to components of the problem in this way may overcome the limitations of a diagnosis-centred approach, and accords with multicomponent-based approaches to illness that are effective in older people.9 Such an approach is also well suited to primary care, where patients present with symptoms, activity limitation and concerns about the impact of the disease on their daily life. Having established that we are dealing with a heterogeneous disease entity with a range of clinical problems, and solutions specific to these problems, what are the barriers to making progress with this disorder? There is evidence of generally poor diagnostic evaluation of symptomatic patients; inadequate availability of some effective therapies, particularly in disadvantaged populations1 and those in rural and remote areas; and lack of services for severely disabled (breathless) patients. Simple interventions such as educating patients on correct use of devices, vaccinations, and prompt treatment of infective exacerbations are not universally implemented. Patients with severe, end-stage airways disease often do not receive appropriate referral for oxygen therapy and frequently miss out on appropriate guidance and discussion of end-of-life issues.10 If these are the barriers to better outcomes for patients with obstructive lung disease, how do we overcome them? Diagnosis is the doorway to effective management and hence improved clinical outcomes. However, for some breathless patients, the correct diagnosis is elusive. Cardiac failure, obesity, anaemia and general unfitness, as well as obstructive lung disease, may individually or collectively cause breathlessness in older patients. Spirometry is crucial to the diagnosis of obstructive lung disease and assessment of its severity, and yet few patients who present with breathlessness have an assessment that includes this procedure. For example, only 6% of general practice encounters for asthma among adults include an assessment of lung function.1 The optimal mechanism for improving patients’ access to spirometry is yet to be established.11 Equipping, training and remunerating general practitioners for performing the procedure is one approach that has been tried12 and may prove more effective as practice nurses are deployed more widely. The alternative is to improve accessibility of specialist pulmonary function laboratories. This latter approach has the advantage of high standards of quality control and linking the procedure to expert interpretation. We need translational research studies to identify the most effective strategy for ensuring that all patients with undiagnosed breathlessness or suspected obstructive lung disease have a valid and reliable objective assessment of their lung function. In a substantial proportion of patients with obstructive lung disease, regular use of inhaled corticosteroids has been shown to be effective in improving a diverse range of clinical outcomes. In particular, patients with reversible airflow obstruction, eosinophilic inflammation,13 severe airflow obstruction and frequent exacerbations gain significant benefits from regular inhaled corticosteroid use.14,15 Research at the Australian Centre for Asthma Monitoring has shown that people who purchase inhaled corticosteroids at the concessional Pharmaceutical Benefits Scheme price are dispensed 2.5 times more prescriptions for these medications than those who pay the full (general beneficiary) price.16 While some of this difference may indicate unnecessary or excessive use, it is clear that a scheme that makes drugs from this class available at a reduced price to those who are most likely to benefit from them and cannot currently afford them will result in substantial health gains. Breathlessness is not only a distressing symptom but also a disabling one. People who are disabled due to breathlessness are poorly served in our community. Exercise-based pulmonary rehabilitation is one intervention that has been shown to help people with this problem. Although many tertiary care hospitals have established programs to deliver pulmonary rehabilitation, their location, predominantly in major centres, means that many people who stand to benefit from these programs cannot access them. We need improved transport services to bring severely breathless patients to the services they need. Surely this is more cost-effective than trying to deliver individualised pulmonary rehabilitation in the home. People who are disabled by breathlessness, either temporarily during exacerbations or permanently, are often institutionalised because they cannot maintain their homes or perform self-care tasks unaided. Provision of enhanced home-help and self-care assistance would enable some of these people to fulfil their desire to stay at home and away from hospitals and other care institutions. As National Asthma Week (1–7 September 2009) approaches, it is time to act now to adopt policies promoting a holistic, person-centred and problem-oriented approach to the care of older people with obstructive lung disease, whether it is labelled as asthma or COPD, or not labelled at all.

Guy B Marks PhD, FRACP · Leanne M Poulos BMedSc(Hons), MPH(Hons) · Christine R Jenkins MD, FRACP · Peter G Gibson MB BS, FRACP

How to succeed at medical school. An essential guide to learning. Dason Evans, Jo Brown. Chichester: Wiley-Blackwell, 2009 (ix + 179 pp). ISBN 978 1 4051 5139 9. The authors of this guide both come from St George’s, University of London, where they work in the Centre for Medicine and Healthcare Education. They have long track records in medical and health science education and as examiners and are well placed to co-author a book such as this. The book endeavours to equip a student to perform well at a British medical school. The curriculum that the hoped-for readers face would be quite familiar to Australian students and faculty, encompassing the spectrum of courses found here. I don’t believe there is another book quite like it. There are similar books from North America, but they are less relevant to this country and tend to concentrate on how to get into medical school and get the residency of your choice, rather than the bit in the middle — the subject matter of this book. Much of this information would be available in the form of student guides and the like in most Australian medical schools, begging the question: will students see the price for a consolidated source of advice as a good investment? This book is, however, a rich and compact source of advice. A medical teacher of many years, I found myself in agreement with virtually the whole book. The background to knowledge and learning are sound. That there is a lot to grasp in medicine, requiring something more than pre-exam cramming, the value of working in teams, the necessity of continuous practice to ensure that clinical skills are like riding a bike — these are all concepts of value to students. Information about the different sorts of examinations and assessments is spot on. The book is easy to read. It is well set out and has good revision points in the form of reflective questions at the end of each chapter. Both teachers and students would benefit from it, although if the publishers seriously want it to sell in Australia they should replace references to the GMC (General Medical Council), and the like, with appropriate Australian ones.

Paul A Gatenby

Younger onset dementia. A practical guide. John R Hodges, Carol Gregory, Colleen McKinnon, et al. Sydney: Alzheimer’s Australia, 2009 (38 pp). Alzheimer’s Australia has been producing the Quality Dementia Care series of useful fact sheets and booklets for people with dementia and their carers but, until recently, had neglected the area of dementia with early onset. This booklet, together with a few others released during the past couple of years, helps rectify the situation. John Hodges, one of the world’s leading authorities on younger onset dementia, gathered a competent group of collaborators to produce this document, which can be freely downloaded from: http://www.alzheimers.org.au/content.cfm?infopageid=5484. The booklet is divided into five sections covering key features of the clinical presentation of younger people with dementia, practical approaches to manage cognitive deficits and behavioural disturbances, issues that are of relevance to carers, preparing for the future (including legal issues), and further resources. The document has a smart layout that will make it easy for readers to find the information they are after; and although information has been maintained at a basic level (basic, but up to date), carers will certainly appreciate the helpful hints on issues related to management, services and how to access other relevant resources. If you work with people with dementia, I would encourage you to keep a few copies of this booklet at hand in your office. I certainly will.

Osvaldo P Almeida

In 6 weeks, swine influenza A(H1N1) virus has spread from 10 to 74 countries. Australia has the fifth highest number of cases and the third highest rate of infection among the top five affected nations. People who are hospitalised with or die from this novel virus are more likely to have predisposing risk factors. There is a predilection for younger age groups and sparing of older age groups. This may be a property of influenza A viruses in general rather than being specific to swine influenza A. If unchecked, the sheer number of cases may lead to much higher numbers of deaths and hospitalised patients than would normally be attributed to a standard influenza season. Paradoxically, the low case-fatality rate of the virus raises the question of how best to approach management of this outbreak. It is uncertain how an expected vaccine against the novel virus will be used.

Sanjaya N Senanayake MB BS, FRACP, MAppEpid

The swine influenza (H1N1 09) outbreak in Victoria has provided an excellent opportunity to review the Australian Health Management Plan for Pandemic Influenza (AHMPPI) and to assess its performance in practice. General practitioners play a major role in seasonal flu management, and it was expected that the AHMPPI would enable GPs on the front line to maintain this central role during the swine flu pandemic. The role of front-line GPs has been made extremely difficult by deficiencies in implementation of the AHMPPI, including resource supply failures, time-consuming administrative burdens, delays in receiving laboratory test results and approval for provision of oseltamivir to patients, and a lack of clear communication about policy changes as the situation progressed. We must use this experience to ensure timely and appropriate review of the AHMPPI and the way it is implemented. Better consultation with front-line clinicians, particularly GPs, is crucial and must occur as a matter of urgent priority.

Peter Eizenberg MB BS

General practice needs resolute and united medical leadership to ensure its fitness for survival Two-hundred years after the birth of Charles Darwin and 150 years after the publication of On the origin of species, we elected to pursue a Darwinian theme in the 2009 MJA annual General Practice issue. “Survival of the fittest” relates to the ability to adapt to the immediate environment, which, for medicine and health care, has certainly undergone some changes! Indeed, the Lancet recently redefined health as the ability to adapt.1 We wanted to explore just how medicine, and general practice in particular, has adapted to changing societal, commercial and political environments. There is no denying that societal changes, coupled with advances in science and technology, have brought substantive changes in health care. Not only are Australians now living longer than ever before,2 but we also enjoy a comprehensive health system that has made us “a nation free from financial worries that go with illness and incapacity”.3 But it must be acknowledged that there are smouldering tensions both within medicine and in its relationship with society — tensions that may well bring about fundamental change in medical practice. These catalysts for change have been comprehensively explored by Lilford and his colleagues from the Department of Public Health and Epidemiology at the University of Birmingham in an essay entitled “Medical practice: where next?”4 First, there is the rise of consumerism and corporatism. These days, medicine in the developed world is practised in societies consumed by consumerism, individual rights, and a low threshold for litigation. As a consequence, we now practise “defensive medicine”. The very word “patient” is decried by some and replaced by “consumers”, “customers” and “clients”, with their inherent service connotations. In fact, medicine has moved from an environment of individual professionals to one of corporate entities, as the financial lodestones of government subsidies and guaranteed cash flows attract corporate interests. Doctors practising in such environments are no longer considered valued partners, but are regarded simply as workers in a health care team involved in the production cycle. Second, administrators and accountants now reign supreme, with an emphasis on organisational performance. One of the unforeseen consequences of this corporatisation of general practice, with its production lines accommodating discrete and circumscribed tasks,5 has been the loss of continuity of care.4 The ever-present problem of patients’ access to health care has led to an increasing displacement of doctors by other health professionals.6 Nowhere is this more evident than in general practice. Doctors might still play a very important role in managing an illness, but they no longer exclusively direct the play. The roles of other primary health care providers and coordinators are evolving, and new tensions are being generated as they become involved in decision making, diagnostic procedures, prescribing and the organisation of referrals. Indeed, the widespread unhappiness and loss of morale among doctors, particularly general practitioners,7 is usually attributed to these and other pressures, especially when accompanied by diminishing autonomy and professional control. When practice frameworks, remuneration and regulations are determined by central bureaucratic commands, disempowerment and loss of professional control will result. Lilford and colleagues are particularly bleak in their predictions for the future, arguing that medicine may well lose its hegemony: What we are arguing is that the link between the work of a health professional and specific ‘professional background’ will become increasingly tenuous. This happened some twenty years ago in chemical pathology and more recently in public health, and the trend is now apparent in subjects as diverse as anaesthesia, primary care and ophthalmology. It is increasingly difficult to define ‘doctor’ in such a way as to distinguish the practitioner unambiguously from other clinicians in the healthcare team who have decision-making responsibility and/or who administer critical interventions.4 They go on to argue that intellectual and communication skills will become the most crucial competencies in health care, and that the consultation will reassert itself as the central encounter in health practice. This special General Practice issue of the Journal contains contributions that explore such diverse topics as the reform of health care policy and general practice (Kidd, Coote, Mara and Sturmberg et al), the development of models of care (Harris et al, Wakerman et al, Phillips et al and Hartigan et al) and medical education in general practice (Laurence and Black, Sen Gupta et al and Sturman et al). Together, they offer some insight into the future direction of general practice. Coote details the reforms in Australian general practice from 1989 to 2009 (Coote).8 He describes how successive governments enacted reform revolving around remuneration, regulation and accreditation, organisational frameworks, and governance. During this process, governments capitalised on the principle of “divide and rule”. This is not particularly difficult in Australia, given the multiplicity of representative bodies and players in general practice, including such diverse organisations as the Australian Medical Association, the Divisions of General Practice, the Rural Doctors Association of Australia and the academic bodies of general practice and rural and remote medicine. Moreover, the federal government is itself a major powerbroker in the reform process, in that a considerable proportion of general practice income is derived from Medicare, and the government effectively controls both the workforce and the scope and diversity of its practitioners.9 Of even more importance, perhaps, is the federal government’s capacity to create ongoing uncertainty with its endless cavalcade of inquiries and their potentialities for change. All of this reinforces the notion that reform of general practice should be fuelled by GPs and shepherded by resolute and united medical leadership. Australian general practice has had effective leadership in the past, but if it is to develop further changes in medical care, it will need a multi-representative overarching body. Sir John Tooke’s inquiry into the United Kingdom’s Modernising Medical Careers debacle made pertinent comments on leadership of the British medical profession that may also apply in Australia: Indeed the advice derived from individual medical professional constituencies frequently reflected the particular interests of that grouping rather than the interests of medicine and medical care as a whole ... At a national level the Inquiry acknowledges that the medical profession has frequently failed to proffer coherent advice on key issues of principle, reflecting in part a very complex organizational structure, which owes more to history than necessarily function or purpose. There has been a dearth of medical professional leadership over this period.10 Here in the Antipodes, things are essentially no different. Without such a structure and courageous leadership, the Darwinian evolution of general practice may well be driven by chance alone or, at the very least, a passive or submissive response to the environments imposed by successive governments, as recounted in this issue by Coote8 and Mara.11 If GPs caring for patients 50 years ago were to return today, they would be amazed by the profound changes that have occurred. Yet one constant remains: general practice will continue to be subjected to changing professional, political and social paradigms. In this environment, unless resolute and united leadership ensures its centrality in the process of reform, general practice will no longer be deemed “the fittest” and, according to the basic principles of Darwinian evolution, will not survive.

Martin B Van Der Weyden MD, FRACP, FRCPA

A compilation of effective non-drug treatments could help increase their uptake in clinical practice In 2004, the Journal published a randomised controlled trial of graded exercise for chronic fatigue syndrome (CFS).1 As with several similar trials, this trial found that graded exercise was an effective intervention. But what is graded exercise? In response to numerous emails from both doctors and CFS patients who wanted further details of the exercise program, the authors of the study published a second article that provided the additional “how to” details and addressed different scenarios.2 I now keep the pdf file of this second article on my general practice computer to give to, and discuss with, CFS patients. The difficulties in accessing information on this simple, non-drug intervention are in stark contrast to the helpful tools available for prescribing pharmaceuticals: formularies, prescription pads, and pharmacies. The problem is not unique to graded exercise. In a review of studies selected for the journal Evidence-Based Medicine, we found that the adequacy of treatment descriptions in trials and systematic reviews appeared to be worse for non-drug treatments than drug treatments,3 with only about 30% of non-drug treatments (compared with 66% of drug treatments) being directly replicable from the information given. Fortunately, obtaining additional information from references, searches and authors increased this figure to around 65%.3 The poor descriptions and lack of easy reference may help explain the slow uptake of some effective non-drug treatments. For example, while the Epley manoeuvre for benign positional vertigo has been known as a simple effective physical treatment for over a quarter of a century, a German survey suggested that it is used in only 8% of affected patients.4 Though many general practitioners seem have heard of it, informal surveys of GPs at large educational seminars have shown that few know how to do it and fewer actually use it. Title page of a 1669 edition of Pliny’s Naturalis historiae, volume 1 For medicinal treatments, the need for an encyclopaedic collection with clear descriptions of how to prepare them was recognised long ago. Pharmacopoeias date back to at least the first century AD, when Pliny catalogued the herbal medicines in use in ancient Rome (Box).5 In the United Kingdom, the first list of approved drugs with information on preparation methods was the London pharmacopoeia, published in 1618. In 1864, the British pharmacopoeia (http://www.pharmacopoeia.gov.uk) was published to try to harmonise pharmaceutical standards through the merger of the London, Edinburgh and Dublin pharmacopoeias. Today, we cannot imagine the practice of medicine without a pharmacopoeia and a formulary. Outside pharmaceuticals, there seems to have been much less compilation and standardisation. This is not for lack of effective non-drug treatments. For example, a survey of 1464 randomised controlled trials supported by non-commercial sources in the UK between 1980 and 20026 found that more than half were for non-drug treatments, such as education, surgery, diet, exercise, and physical and psychological therapies. Although some of these are picked up by the relevant professions, many seem to fall between professional boundaries. For example, “bibliotherapy” (providing patients with informative reading material on self-management of their condition) has been used successfully in treating depression7 and irritable bowel syndrome.8 What would a formulary of non-drug therapies look like? Although an extensive compendium of all non-drug treatments would be worthwhile, for clinicians a non-drug formulary should be restricted to interventions shown to be effective by randomised controlled trials or other definitive evidence.9 As with drug formularies such as the British national formulary (http://www.bnf.org/bnf) or the Australian medicines handbook (http://www.amh.net.au), a non-drug formulary should also contain information on indications, contraindications and precise details of treatment. To be sufficient for a practitioner to replicate the treatment delivered in the trials, the treatment details will commonly need to be longer than the dosage, duration, and titration information typically given for pharmaceuticals. However, with the move to online information access, there are now minimal restrictions on space. Many journals now allow supplements, including video material, to be included with online versions of research articles. For example, the Journal of Visualized Experiments (http://www.jove.com) was established to capture the intricacies of life science research by providing online videos of experimental procedures. For non-drug interventions, it is essential that details of procedures and treatments are not copyright to a specific journal but are made freely available. Although pharmaceuticals have been central to many breakthroughs in medicine, non-pharmaceutical advances — in areas such as behavioural therapy, exercise therapy and nutrition — also offer many benefits, but their uptake has been less. For GPs, but also for the many discipline specialists, a non-drug handbook would be an important tool to foster a more balanced use of evidence-based treatments. I would like one on my clinic desk tomorrow, please.

Paul P Glasziou MB BS, FRACGP, PhD

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

Michael R Kidd MD, FRACGP

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

William Coote MB BS, FRACGP, BEc

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

Paul R Mara DipRACOG, FRACGP, FACRRM

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

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

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

Susan M Wearne MMedSc, FRACGP, FACRRM

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

Thomas D Brett

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Julaine M Allan · Patrick Ball · Margaret M Alston