General medicine

Objective: To understand general practitioners' experiences of managing patients with chronic leg ulceration, thus informing future strategies to improve leg ulcer care in general practice.Design: Qualitative study using phenomenology and in-depth interviewing.Participants and setting: Maximum variation sample of 12 GPs working in the Perth and Hills Division of General Practice between September and December 2004.Main outcome measure: Themes in participants' experiences of leg ulcer care.Findings: Participants regarded leg ulcer management as an integral part of general practice. They expressed a desire to maintain their involvement, yet relied on nursing assistance. They perceived that ulcer care was usually straightforward and successful. Approaches to management appeared to differ significantly from that outlined in current guidelines. Instead, participants valued accessibility of care for the patient, awareness of patient context and regular review. Occasional problems with non-healing ulcers were experienced, and, in these situations, specialist opinion was appreciated.Conclusion: This study highlights fundamental differences between GP and specialist conceptualisation of leg ulcer care. For GPs, it identifies key areas of ulcer management that could be improved. For specialists, it suggests that widespread implementation of traditional guidelines may not be appropriate or acceptable. New approaches to leg ulcer management in general practice are likely to need a combination of education, human resources and practical support.

Genevieve M Sadler MB BS · Grant M Russell FRACGP, MFM · Duncan P Boldy MSc, PhD · Michael C Stacey FRACS, DS

Rare diseases affect 6%–10% of the population, which equates to about 1.2 million people in Australia having a rare disease. The United States, the European Union and many other nations have coordinated policies and patient advocacy groups for rare diseases as a group. Australia has enacted orphan drug legislation, but there is no coordinated approach either from government or from patient groups. General practitioners see rare diseases commonly, but their role for this group has not been adequately described. People with rare diseases and their families have similar experiences despite their different diagnoses. GPs are well placed to help with these problems. The development of a generic general practice strategy for these patients may improve their overall care.

Andrew W Knight MB BS, FRACGP, MMedSci(ClinEpid) · Timothy P Senior BM BCh, FRACGP

Objective: To assess the availability of computers to general practitioners and individual GPs’ use of computers for clinical functions.Design, setting and participants: A secondary analysis of data from a random sample of 1319 Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) survey, a continuous cross-sectional survey of general practice activity, between November 2003 and March 2005. Participants reported the availability of computers at their major practice address and the clinical functions for which they used the computers.Main outcome measures: Proportion of practices with computers available; proportion of individual GPs who used computers for clinical purposes.Results: The proportion of GPs not using a computer was 11.2% (6% did not have a computer at their major practice address and a further 5.2% chose not to use an available computer). The majority of GPs using a computer at work used it for electronic prescribing (94.7%), ordering tests (82.2%) and keeping some patient data in an electronic medical record (79.5%). Of those with clinical software available (n = 1114), 6.6% chose not to use it. A third of GPs (32.8%) kept all patient information in an electronic format. The proportion of GPs keeping all data electronically and using all clinical functions available in their computer was 21.7%.Conclusion: While the physical presence of computers has increased significantly over the past decade, GPs are still reluctant to fully embrace the technology.

Joan Henderson BAppSc(HIM)(Hons) · Helena Britt BA(Psych), PhD · Graeme Miller MB BS, PhD

Objective: To describe how general practitioners use computers for clinical purposes.Design: Mail survey of a cross-sectional national stratified random sample of 3000 GPs in primary care settings between 10 October and 31 December 2005.Main outcome measures: Use of computers, and use of computerised clinical functions such as prescribing, medication checking, generating health summaries, running recall systems, and writing progress notes.Results: Of 1186 GPs responding (39.5% response rate), 90% used a clinical software package. GPs used clinical packages for prescribing (98%), checking for drug–drug interactions (88%), recording a reason for prescribing (65%), to order laboratory tests (85%), run recall systems (78%), and record progress notes (64%). Less frequently used functions included generating lists of patients needing vaccines (43%) and taking the same medication (39%). Less than 20% of GPs who used a clinical package accessed computerised information during the consultation.Conclusions: Australian general practice has achieved near-universal clinical computerisation. Electronic prescribing alone has probably improved efficiency and quality of care, and reduced medication errors. Increasing the use of other functions, such as accessing online decision support and maintaining registries of patients, is likely to lead to further health gains, especially in managing chronic conditions.

D Keith McInnes MS · Deborah C Saltman AM, MD, FRACGP, FAFPHM · Michael R Kidd MD, FRACGP

The Internet and computers have brought immense change in how society deals with information. Uptake of these technologies has been disjointed and has occurred in a non-uniform way among general practitioners, compared with other professionals. Information mastery is a key 21st century skill that GPs should acquire. Applying “change management” concepts may help improve uptake of information mastery skills in general practice.

Justin Tse MB BS, MMed, FRACGP · Brian R McAvoy MD, FRACGP, FRCP

A solution in search of a problem? At first glance, the modish and engaging concept of “information mastery” is a reasonable one to apply to general practice, but on closer inspection, it may be a misdirected application of current information technology (IT). There are four reasons for this. First, computerised information systems have some way to go before they can usefully contribute to a general practice consultation in the manner proposed. The process of searching for and retrieving information from a clinical database currently takes several minutes at best. The search engine, Google, gives hope that improved search algorithms and computer interfaces will reduce this, but even if relevant information were provided instantly, time is still required by humans to read and understand it. The process of retrieving and digesting information distracts doctors from relating to patients, which is the primary task in a consultation. So, while there is an essential requirement for evidence to inform practice, it is difficult to see IT offering a major improvement on how this can be done during the consultation. Second, the application of IT to “information mastery” overlooks a simpler, currently more useful, aspect of computing which can be integrated into current GP work practice. Computers are good at simple, repetitive tasks; humans are not. There is abundant evidence of the value that computers can bring to quality assurance processes, such as checking drug doses and drug–drug interactions.1 A number of Divisions of General Practice have developed computerised systems which ensure that patients with chronic diseases receive interventions proven to improve their outcomes. These applications are simple things done consistently, and do not require the more abstract objective of “information mastery”. Third, the application of IT in health care is high risk: it is infrequently and inadequately assessed, and when it is assessed, it is often found not to be cost-effective.2 It follows that there is no advantage in being an early adopter of IT. A more effective strategy is to let others test whether a particular application works and wait for the costs to fall — they always have in IT! Finally, and not uncommonly in IT, “information mastery” seems to be a solution in search of a problem: even if it were to deliver the benefit it promises, it offers more of the same, not an improvement. Throughput may increase, but quality need not. If our objective is to improve health care, then we need to start with health care problems. This may lead us to IT as a tool to provide relevant and timely information, but it needs to do so in a manner that supports patient care, rather than dictating it.

Patrick G M Bolton PhD, FRACGP

Objective: To determine the incidence of errors anonymously reported by general practitioners in NSW.Design: The Threats to Australian Patient Safety (TAPS) study used anonymous reporting of errors by GPs via a secure web-based questionnaire for 12 months from October 2003.Setting: General practices in NSW from three groupings: major urban centres (RRMA 1), large regional areas (RRMA 2–3), and rural and remote areas (RRMA 4–7).Participants: 84 GPs from a stratified random sample of the population of 4666 NSW GPs — 41 (49%) from RRMA 1, 22 (26%) from RRMA 2–3, and 21 (25%) from RRMA 4–7. Participants were representative of the GP source population of 4666 doctors in NSW (Medicare items billed, participant age and sex).Main outcome measures: Total number of error reports and incidence of reported errors per Medicare patient encounter item and per patient seen per year.Results: 84 GPs submitted 418 error reports, claimed 490 864 Medicare patient encounter items, and saw 166 569 individual patients over 12 months. The incidence of reported error per Medicare patient encounter item per year was 0.078% (95% CI, 0.076%–0.080%). The incidence of reported errors per patient seen per year was 0.240% (95% CI, 0.235%–0.245%). No significant difference was seen in error reporting frequency between RRMA groupings.Conclusions: This is the first study describing the incidence of GP-reported errors in a representative sample. When an anonymous reporting system is provided, about one error is reported for every 1000 Medicare items related to patient encounters billed, and about two errors are reported for every 1000 individual patients seen by a GP.

Meredith A B Makeham MPH(Hons), FRACGP · Michael R Kidd MD, FRACGP · Deborah C Saltman AM, FRACGP, FAFPHM · Michael Mira MD, SS, PhD · Charles Bridges-Webb AO, MD, FRACGP · Chris Cooper MRCGP, MPH · Simone Stromer FRACGP

Objective: To investigate the feasibility, achievement and acceptance of indicators of quality general practice in the RACGP Standards for general practices (third edition), using complaints registers as a case study.Design, setting and participants: A purposive sample of convenience of 200 general practices (stratified according to location and size) participated in a field test of quality and safety proposals during an accreditation survey visit between October 2004 and February 2005. Included was a test of the proposal for a complaints register (a document where complaints made to the practice are recorded).Main outcome measures: Achievement of the complaints register proposal, assessed by accreditation surveyors; questionnaire rating of the feasibility and acceptance of the proposal.Results: Few practices used a formal complaints register (79/200; 39.5%), with large practices more likely (12/20; 60.0%) and very remote practices less likely (1/11; 9.1%) to use one. The proposal for complaints registers was rated feasible by 123 general practices (61.5%) and rated acceptable by 121 general practices (60.5%).Conclusions: The proposal for complaints registers in general practice, while popular with policymakers, gained limited support when tested in Australian general practice. This shows the need for a balance between the expectations of policymakers, the need to increase performance by setting standards, and the practicalities of every-day general practice.

Ronelle L Hutchinson BA(Hons), PhD · Ian T Watts BSW, DipSocPlan, MBA(Exec)

Objective: To compare general practice career choices of four cohorts of medical graduates.Design and setting: Retrospective longitudinal study of medical graduates. Data on employment since graduation, nature of current employment, and postgraduate qualifications were collected by postal survey in 2003.Participants: Four cohorts of Monash University Medical School graduates who completed their degrees in 1980, 1985, 1990 and 1995 (n = 386).Main outcome measure: Proportion of each cohort pursuing a general practice career.Results: At 8 years after graduation, half of the graduates in the 1980 and 1985 cohorts were working in general practice, compared with 38% of 1990 graduates and 33% of 1995 graduates. Differences were mainly attributable to fewer female graduates working as GPs: female GPs comprised 62% of the 1980 cohort compared with 31% of the 1995 cohort. Graduates in more recent cohorts also entered the general practice workforce at a later stage than those in earlier cohorts.Conclusion: A rapidly declining proportion of new graduates from Monash University Medical School, particularly female graduates, are choosing general practice as a career. This will exacerbate future shortages in the general practice workforce.

Catherine M Joyce BA(Hons), MPsych, PhD · John J McNeil PhD, FRACP, FAFPHM

Despite the size and importance of primary health care (including general practice) within the health system, traditional research output has been relatively low, both here and overseas. General-practice and primary-care research in Australia has been criticised for the preponderance of small-scale, descriptive and survey-based studies. If we are to conduct larger-scale clinical, epidemiological and health-services research, new structures and processes are needed. The research networks set up under the first phase of the Australian Government’s Primary Health Care Research, Evaluation and Development (PHCRED) Strategy have tended to focus on up-skilling, research literacy and dissemination. This is important, but for general-practice research to evolve, a new type of practice-based research network is needed. These new practice-based networks require commitment and funding from policymakers, a base in academic departments, plus active involvement from Divisions of General Practice and the practitioners themselves.

Nicholas A Zwar MPH, PhD, FRACGP · David P Weller PhD, FRACGP, FAFPHM · Lucy McCloughan BSc(Hons), PhD · Vanessa J Traynor BA

Objective: To find out what supports effective links between Divisions of General Practice and universities.Design: Qualitative study based on semi-structured interviews during October 2004, from which a framework for effective linking was constructed and its validity assessed by discussion with researchers and Division staff and members at four interactive workshops held between 9 November 2004 and 5 November 2005 .Participants: 21 participants from Divisions of General Practice and universities in Australia.Results: Qualities conceptualised as “opportunity” and “fair relationships” were critical factors in establishing successful links between the two sectors. The relationship between these two factors describes the types of interactions that currently occur.Conclusions: To develop effective links requires an environment that promotes adequate opportunities, and in which mutual trust can grow. This will require commitment and system change from all parties.

Elizabeth C Kalucy BSc, MSc, DipEd · Christopher M Pearce FRACGP, FACRRM, MFM · Barbara Beacham BSocSc · Belinda L Lowcay BBehavSc · Rachel E Yates BTec(UK), BSci(Hons)

Primary health care is the foundation of effective, sustainable population health and is associated with higher patient satisfaction and reduced aggregate health spending. Although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research. The pace of research activity in general practice and the rate and quality of publications do not match the pace of structural change or the level of funding provided. Recruitment difficulties are a major impediment, fuelled by general practitioners’ time constraints, lack of remuneration, non-recognition, and workforce shortages. Radical reform is required to redress imbalances in funding allocation, including: funding of GP Research Network infrastructure costs; formalising relationships between primary care researchers and academic departments of general practice and rural health; and mandating that research funding bodies consider only proposals that include in the budget nominal payments for GP participation and salaries for dedicated research nurses.

on behalf of the CHAT Study Group

A strong primary medical care system is essential to the equity, efficiency and effectiveness of the health system as a whole. General practice in Australia faces significant challenges to its capacity to fulfil its role and function: in its financing, recognition, capacity to provide comprehensive care, and integration with the rest of the health system. Addressing these challenges requires a better system of remuneration for quality in general practice care, strengthening of the role of the generalist within the health system, involvement of Divisions of General Practice in service development, and establishment of collaborative networks and integrated primary health care services.

Mark F Harris DRACOG, FRACGP, MD · Elizabeth Harris DipEd, DipSW, MPH

The future role and structure of Australian general practice remains uncertain, despite a decade of seemingly constant change following the release of the National Health Strategy papers. Some of the suggested change strategies (such as rural Practice Incentive Payments and practice accreditation) have been implemented; others (such as general practitioner involvement with area health authorities in delivering national goals and targets for communities) still await attention. An overarching vision for our health care system in 2020 and general practice’s role within it are still to be clearly enunciated. Australia is at variance with other Western countries, such as the United Kingdom, Canada and New Zealand, which have spent significant time refocusing their health systems to deal with an ageing population with an increased burden of chronic disease. Health bureaucrats and governments need to invest strategically in operational primary care now. This will require the active commitment of general practice’s national bodies to articulate and actively promote a shared vision for Australian general practice.

Claire L Jackson MPH, GradCertMt, FRACGP

To the Editor: Bachrach’s article1 “Missed conceptions” and the accompanying commentary by Chapman et al2 made compelling reading. The plea of these authors coincides with calls from the Fertility Society of Australia and the South Australian branch of the Australian Federation of Business and Professional Women for campaigns to better inform women about the biological limits of their fertility. Personal stories can alert us to social problems sliding under the radar. But before we heed the call for “positive family planning”, we need to know more. Firstly, whether intervention by a general practitioner (as Bachrach, in her forties and wanting children, would have wished) would be appreciated by younger women who may not yet, or may never, be interested in motherhood. We also need to know how GPs would view this sort of intervention, and whether they feel equipped with the knowledge and tools to ensure an effective engagement that is appropriately respectful of their patient’s autonomy. There is a long history of women being valued by society only as mothers. It is important that any GP-based fertility intervention be sensitive to a woman’s fertility values and plans, be they for motherhood or freely chosen childlessness. Bachrach’s article is a call for action, but we need to ensure that action is well grounded in research-based knowledge about current practice and the barriers both GPs and women perceive to discussing fertility plans in the consulting room. Such knowledge would be useful for the development of a tool to assist GPs in helping women make timely, well informed fertility decisions that are consistent with their parenting plans.

Danielle Mazza · Leslie Cannold · Cate Nagle

We must preserve the elements of our health care system that work well All the signals in health care in the Western world point towards increasing demand and limitations on supply — a development driven by ageing populations, ever-increasing and sophisticated technologies and treatments, and a workforce that is less inclined to work the long hours of years gone by. There have been calls from governments for more flexibility in health care delivery. In the case of primary care, the arguments for substituting “traditional” general practitioner roles seem compelling — primary care in the United Kingdom and Australia is struggling to provide adequate access to care for a population with increasing needs. Surely we must expand our workforce to meet this need — especially if this can be achieved by employing less expensive health care providers? In this issue of the Journal, Sibbald and colleagues review the current status of workforce substitution between nurses and GPs.1 They point to the variety of roles that nurses have adopted in primary care settings: there seems compelling evidence that nurses can, with a great deal of autonomy, effectively deliver routine management of chronic conditions, such as asthma, diabetes and coronary heart disease. Indeed, further roles for nurses, such as cognitive behavioural therapy for psychological problems, are continually being explored.2 The new contract between GPs and the UK National Health Service (NHS), while rewarding GPs for meeting quality targets, underpins nurse-led management with specific chronic disease targets and a strong focus on clinical audit.3 There seems no doubt that nurses can take the lead on these processes effectively and produce favourable clinical outcomes — acknowledging that successful GP–nurse work substitution is, indeed, context dependent, and accepting that issues such as continuity of care, legal liability and practicalities of prescribing are paramount.1 Also in this issue, Parle et al discuss the development of a “medical care practitioner” curriculum in the West Midlands4 — there is considerable interest in bringing this North American model to the UK. On the whole, the pilot study by investigators at the University of Birmingham of the impact of US-trained “physician assistants” on the NHS indicated that introducing this new kind of health care provider into primary care can ease demand.4,5 Further, they have generally been met with positive responses from both their practice colleagues and patients. However, can we assume that because primary care capacity is insufficient there is an “overwhelming need for a mid level clinician working under the supervision of a qualified doctor”?3 The need for extra capacity is being met in part by new doctors. In common with Australia, the UK has chosen to increase student numbers to meet projected future requirements,6 and to reduce to a large extent the dependence on international medical graduates to fill both training scheme places and service posts. The number of places at UK medical schools increased by almost 60% between 1998 (when there were about 3750 places) and 2005, as a result of introducing new 4-year graduate entry programs, establishing four new medical schools, and adding places to existing schools. These new doctors are yet to have an impact on the workforce, but this greater capacity must inevitably influence access. A legitimate role for medical care practitioners seems apparent in secondary care settings, where the arguments of fluctuating skills of junior doctors and trends towards increased specialisation have more salience. In primary care it’s more complex: in Australia and the UK, primary care has been much more central to health service provision than in North America, and we know that a strong primary care focus within health systems can produce favourable health outcomes.7 The US physician assistants (the equivalent of medical care practitioners) have had a significant effect on primary care services,8 but it’s a different environment to ours. While there is something to be said for a mixed economy of approaches to workforce in primary care, there are inherent dangers in drifting towards a system in which primary care is seen as a “second tier” in the health service. A great deal of effort has been invested in trying to promote integration between primary and secondary care, and there are many efficiencies and health gains that can be achieved in doing so. A growing gap between primary and secondary care, in which the two workforces develop fundamental structural differences, can only inhibit this process.9 UK government White Paper, Our health, our care, our say: a new direction for community services13 — key features There is a strong focus on patient involvement in planning and decision making There is an emphasis on partnerships; for example, between health services and local authorities Care is to be moved out of hospitals and “nearer to patients’ homes” Encouragement is given to new entrants, including the private sector, as primary care providers Hence, we need to approach with caution any new innovation that potentially marginalises primary care. While investigating the potential of new layers of health professionals, primary care needs to diversify to meet changing needs. A great deal of diversification is already underway, much of it aimed at improving access, albeit with its own “health warnings”. For example, the development of “GPs with special interests” can improve access to much-needed specialist services. However, it needs to happen in a way that preserves continuity, and the universal, comprehensive nature of primary care.10 Similarly, in Australia, the development of primary care clinics for skin cancer, women’s health and travel medicine has both benefits for access and threats — some argue it undermines the fundamental principles of general practice.11 Developments in informatics and e-health hold further potential for improving access. Increasingly, we are looking at different models of consultation — email and telephone consulting, and greater, quality-assured use of the web hold great promise.12 The UK government’s recent White Paper, Our health, our care, our say: a new direction for community services, while provoking some controversy, has highlighted the importance government places on access to primary care, and points the way towards redesign of referral and treatment pathways, and better use of information technology — diversification of providers is highlighted as one of several options (Box).13 There is a need to keep an open mind about diversification and workforce substitution. While examining the potential of new kinds of health care providers, we should exercise caution before committing significant resources, and ensure we preserve the elements of our health care systems that work well. In the case of primary care, many innovations, which may have equal potential to improve access, are already underway (so we shouldn’t “throw out the baby with the bath water”!). So far, the detailed studies comparing these different approaches to improving access are still to be done.

David P Weller PhD, FRACGP, FAFPHM

Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients. Reductions in cost are context dependent and rarely achieved. This is because savings on nurses’ salaries are often offset by their lower productivity (due to longer consultations, higher patient recall rates, and increased use of tests and investigations). Gains in efficiency are not achieved when GPs continue to provide the services that have been delegated to nurses, instead of focusing on the services that only doctors can provide. Unintended consequences of extending nursing roles include loss of personal continuity of care for patients and increased difficulties with coordination of care as the multidisciplinary team size increases. Rapid access to care is, however, improved. There is a high capital cost involved in moving to multidisciplinary teams because of the need to train staff in new ways of working; revise legislation governing scope of practice; address concerns about legal liability; and manage professional resistance to change. Despite the unintended consequences and the high costs, extending nursing roles in primary care is a plausible strategy for improving service capacity without compromising quality of care or health outcomes for patients.

Bonnie Sibbald PhD, FRCGP(Hon) · Miranda G Laurant MSc · David Reeves PhD

A range of demographic, social and other factors are creating a crisis in the provision of clinical care in the United Kingdom for which the physician assistant (PA) model developed in the United States appears to offer a partial solution. Local and national moves are underway to develop a similar cadre of registered health care professionals in England, with the current title of medical care practitioners (MCPs). A competence and curriculum framework document produced by a national steering group has formed the basis for a recent consultation process. A limited evaluation of US-trained PAs working in the West Midlands region of England in both primary care and acute secondary care suggests that PA activity is similar to that of doctors working in primary care and to primary care doctors working in the accident and emergency setting. The planned introduction of MCPs in England appears to offer, first, an effective strategy for increasing medical capacity, without jeopardising quality in frontline clinical services; and, second, the prospect of increased flexibility and stability in the medical workforce. The deployment of MCPs may offer advantages over increasing the number of doctors or taking nurses out of nursing roles. The introduction of MCPs may also enhance service effectiveness and efficiency.

Jim V Parle MD, FRCGP · Nick M Ross MA · William F Doe FRCP, FRACP, FMedSci

The workforce crisis in Australian general practice provides an impetus to consider new roles for other health professionals. Any innovations need to be appraised in advance for their potential risks and benefits. We propose six principles for this appraisal. These are the need for the new roles to: support the relationship between patients and their general practitioners; be clearly defined, aligned with competency and with relevant professional registration; be supported by practice systems providing safeguards against medical error; be underpinned by a system ensuring informed patient consent to activities being undertaken by members of the general practice team; be supported by effective medical indemnity insurance and be supported with appropriate financing.

Michael R Kidd MB BS, MD, FRACGP · Ian T Watts BSW, DipSocPlan, MBA(Exec) · Christopher D Mitchell BMed, FRACGP, FACRRM · Lynton G Hudson FRACGP, DipObsRACOG · Beres C Wenck MB BS, FAMA · Naomi J Cole BNsg, BJS

Health service imperatives such as workforce shortages of doctors and nurses and changing models of care are driving task transfer in Australia. The Royal Australasian College of Physicians (RACP) supports task transfer both across its specialty groups and to other health professionals as appropriate. The RACP’s new education standards, with explicit curricula and competency-based assessments, underpin its capacity for task transfer. Task transfer must be evidence-based, safe, cost-efficient and facilitate best patient care.

Jillian R Sewell MB BS, FRACP

To the Editor: Three recent articles discuss Australia’s medical education arrangements,1-3 but do not propose a way forward. Dahlenburg notes “at least 10 different agencies are involved in postgraduate training”, leading to a “modern Tower of Babel”, but proposes eight more “independent” entities. McGrath et al comment timidly that a Productivity Commission suggestion for a national advisory council “has merit”, and Dowton et al simply comment: “It is time to comprehensively review the oversight and governance of postgraduate medical education and training.” None of these articles even mentions General Practice Education and Training (GPET), an innovative Australian initiative. GPET was established in 2001 as an incorporated entity with a board appointed by the federal Minister for Health. GPET has established regional training providers (RTPs) across Australia. GPET is required under its constitution and government funding arrangements to provide postgraduate training according to standards determined by medical colleges. For general practice, GPET provides features these authors find lacking in Australia’s medical education arrangements, such as “overarching governance and coordination”, “integrated mechanisms to draw together the interests of stakeholders”, “alignment between workforce planning, education and training needs” and “alternatives to teaching hospitals”.4 GPET manages the interaction between autonomous colleges and a funding agency, and conflict between the focused desires of young doctors and workforce policies, while organising training outside public hospitals. Change is difficult, perhaps more so in medicine than in other sectors. Michael Foot, once leader of the British Labour Party, reflecting on political differences with the British Medical Association, wrote: “Much the strongest bent in the medical mind was a non-political conservatism, a revulsion against all change, a habit of intellectual isolation which enabled them to magnify any proposals for reform into a totalitarian nightmare. Nothing good could ever come from the meddling of outsiders.”5 GPET was a political response to effective lobbying from rural doctors rather than imposition of some grand centralist plan. Nevertheless, the imagined threat to professional autonomy evoked gloomy foreboding about “training standards spiraling downwards”.6 Maybe Dahlenburg, McGrath and Dowton realise controversy would follow any proposal for a medical education system with attributes they see missing, such as overarching governance, more coordination, alignment of workforce needs with trainee numbers, and wider distribution of training resources. It might require some consolidation of organisations, common structures and processes across disciplines, and some direction in the distribution of training resources. Maybe these authors do enough by raising the issues and are wise to leave others to debate whether centralised control and coordination could solve the problems they describe. Maybe they took the advice of a well known Englishman and decided not to mention the war.7

William Coote

To the Editor: In an editorial in the 3 April 2006 issue of the Journal,1 Roughead and Lexchin estimated the annual incidence of adverse drug events (ADEs) in patients presenting to general practitioners, based on our data presented in the same issue.2 Calculating the incidence of ADEs from general practice encounter data is fraught with difficulties. Roughead and Lexchin’s calculation depends on all general practice patients having an equal chance of being in the sample. This would only hold true if all patients attended their GP an equal number of times. However, in our study, the age distribution of patients with ADEs shows that they are more likely to belong to older patient groups with a much higher than average general practice attendance rate. They thus represent a smaller proportion of all general practice patients, as their chance of being in the sample is much higher. Adjusting for the age and sex distribution results in an estimated incidence of about 1.6 million people. Further, these 1.6 million would, if asked, have reported an ADE in the previous 6 months. This cannot be extrapolated to an annual incidence of ADEs. The annual incidence figure could in fact be larger than that suggested by Roughead and Lexchin. We believe that recurrent monitoring of ADEs in patients attending general practice is a useful way of measuring the impact of the interventions suggested by Roughead and Lexchin, regardless of the difficulty of extrapolating to population incidence.

Graeme C Miller, Associate Professor and · Helena C Britt · Lisa Valenti · Stephanie Knox

Guidelines for GPs need to tackle the tough issues These are interesting times in Australian mental health. On a daily basis, the gap between best practice guidelines and the quality of services delivered widens. Rapid advances in clinical neurosciences give us real enthusiasm for new approaches to treatment. By contrast, national and state-based inquiries highlight fundamental failures in acute and ongoing care. Although major service redevelopments continue, we do not yet provide an integrated health services response. All our governments now concede that a new round of investment, innovation and coordinated reform is essential. Substantial new investments are justified and necessary if we are to see genuine innovation, improved access to care, and better health outcomes in the mental health service environment. The production of guidelines for bipolar disorder internationally reflects the therapeutic gains that should be available for people with this common and disabling illness.1,2 However, when guidelines target general practitioners, like the recommendations provided by Mitchell et al in this issue of the Journal (The management of bipolar disorder in general practice),3 some hard questions need to be asked. Are they relevant to general practice in Australia? Do they connect with the target audience? Are the recommendations achievable in our health care environment? In recent years, most GPs feel that they have received truck loads of worthy guidelines from their specialist colleagues. Although guidelines are critical to improving health care quality, in the end most fail to recommend strategies that lead to real impacts on clinical practice. The mental health field is no exception. It too is awash with new guidelines.4 Surprisingly, given that 75% of mental health consultations take place in the primary care environment, few have targeted general practice. A notable exception is the guidelines for the treatment of depression in general practice settings, commissioned by beyondblue: the national depression initiative.5 From a GP’s perspective, most mental health guidelines don’t concede basic service limitations. First, GPs are not an unlimited mental health resource. In fact, recent data indicate a major slowing in the rate of increase in the treatment of common mental disorders in primary care settings.6 Second, mental health guidelines compete with all other medical guidelines for attention. Simply producing more guidelines for more disorders doesn’t increase the likelihood that recommendations will be put into action. Producing more guidelines for closely related topics (eg, bipolar depression,3 major depression in specialist settings,7 major depression in primary care,5 youth depression8) also doesn’t help. Third, simply extrapolating evidence from studies conducted in patients with severe, chronic or complex disorders encountered in specialist treatment centres may not only be scientifically questionable, but may particularly annoy GPs.9 Most importantly, “GP guidelines” for mental disorders should deal explicitly with the key issues: identification of less severe forms of the disorder; management of medical comorbidity; overlap with alcohol and substance misuse; limited geographical and economic access to specialist psychological support; use of alternative treatments for less severe or less complex cases; and implications of poor access to specialist assessment during acute phases of illness. Providing a detailed list of reasons for specialist referral does not assist those GPs who struggle on a daily basis to connect with any specialist support in the private or public sector. Rather than addressing such issues, specialist psychiatry has a particular knack for creating more disorders, more subcategories and more complex treatment regimens.1-3 The self-explanatory nature of manic-depressive illness has been replaced by the more opaque terms “bipolar I”, “bipolar II”, “bipolar depression”, “mixed episodes”, “rapid cycling”, and “cyclothymia”. However, if such fine-grained differentiation is not associated with quite specific differences in treatment or prognosis, or is not based on a solid evidence base,10 then it holds little appeal. The medical, psychosocial and legal consequences of a GP making a diagnosis of bipolar disorder are potentially considerable. To suggest that these can be minimised by having all such decisions reviewed by a specialist is highly optimistic, especially given the decreasing availability and inequitable access to such resources. While recent improved access to psychological therapies through partnerships in general practice,11 and proposed direct referral mechanisms to clinical psychologists,12 are most welcome, it is not yet clear whether these developments will increase access for patients with bipolar disorder to the more intensive and targeted therapies they require. From a primary care perspective, the most useful mental health guidelines tackle the tough issues that cross a GP’s desk on a daily basis.9 Where are the best sources of self-help, self-monitoring, detailed illness descriptions, and family education to be found? Are there high quality e-health resources available?13 What options are available to a GP when patients become a danger to themselves or their reputations? How should a GP deal with poor compliance? What are the cost implications for patients of particular management plans (eg, costs of travel to specialist appointments)? What should the GP do when specialist services are not available? What are a GP’s responsibilities when the patient doesn’t return for follow-up appointments and/or medication monitoring? How should a GP document mental health consultations in their medical records? What other clinical or management resources are available? Is additional training required to deliver the therapies recommended in the guidelines? While the recommendations presented by Mitchell et al,3 and the related technical summaries, do provide useful clues, insufficient attention to these practice-based issues risks an overall negative rating from the target audience.

Ian B Hickie MD FRANZCP · Grant A Blashki MD, FRACGP

General practitioners have a key role in managing patients with bipolar disorder, a condition which affects at least one in 200 Australians each year and is the sixth leading cause of disability in the population. Although diagnosis and treatment of the illness is complex, effective treatment can lead to good outcomes for many patients. GPs can contribute significantly to early recognition of bipolar disorder, avoiding the long delays in accurate diagnosis that have been reported. As in other complex recurrent or persistent illnesses, GPs are well placed to coordinate multidisciplinary “shared care” with specialists and other health care professionals. GPs also provide continuing general medical care for patients with bipolar disorder, and are in a unique position to understand patients’ life circumstances and to monitor their progress over time. The last decade has seen many advances in medication for bipolar disorder, including the introduction of new therapies and the refinement of treatment protocols using older medications. There has also been increasing recognition of the contribution of psychological therapies to symptom relief, relapse prevention, optimal function, and quality of life.

Philip B Mitchell MD, FRANZCP, FRCPsych · Jillian R Ball PhD · James A Best MB BS, FRACGP · Bronwyn M Gould MB BS, MPsycholMed · Gin S Malhi MD, FRANZCP, MRCPsych · Geoffrey J Riley MRCPsych, FRANZCP, FRACGP · Ian G Wilson PhD, FRACGP

Helping patients sort out the complexities of life, even if in small steps, can be a source of great satisfaction Aboriginal community controlled health services (ACCHSs) across Australia are supported by predominantly non-Indigenous doctors. As of 2005, there were between eight and ten Indigenous doctors working in ACCHSs. For many non-Indigenous doctors, working in an Aboriginal health service has been a choice to do something different and to try to make a difference. One of us (K S P) moved to Townsville from Sydney. Working for the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to combine general practice with interests in maternal and child health and clinical research. For Indigenous doctors, the reasons for working in an ACCHS are varied, but generally centre on wanting to work closely with their community. The other author (M W) is one of two Aboriginal GPs working at WuChopperen Health Service. Communities and family members, but also the medical community and government, expect Indigenous doctors to work directly in primary health care. In taking on this role, Indigenous doctors need to be able to respond to a variety of community, leadership and role-model pressures, but their value to the local community is measured not only by their natural cultural communication skills, but by the capacity development among Indigenous people that they represent. OpportunitiesIndividual level: the art of medicineThe practice of medicine in an ACCHS challenges even the most highly trained clinician. The number, complexity and interaction of problems presenting in any one consultation1 require listening skills, a depth of clinical knowledge, familiarity with evidence-based medicine, and the ability to formulate feasible management plans2 — and all these skills are needed all the time. A constant challenge is to tease out the subtleties in communication. Inherent in this is the ability of the practitioner to engage in empowerment strategies with Indigenous patients, and a big part of the job is advocacy on behalf of patients, helping them to negotiate parts of the health system compromised by institutionalised racism.3 Diseases such as impetigo, diabetes, and chronic obstructive airway disease are well recognised, but often not only their prevalence but their severity at initial presentation is overwhelming. There is also the need to rapidly acquire the knowledge to manage less familiar diseases, such as rheumatic fever (and its sequelae), syphilis and tuberculosis. Working with teamsACCHS doctors work in multidisciplinary teams. Aboriginal health workers’ and registered nurses’ knowledge of both the cultural and social aspects of a patient’s background are vital to patient management, and they often work independently on aspects of the care plan. ACCHSs are often well supported by visiting specialists and allied health professionals, allowing GPs to work within a truly multidisciplinary primary health care team. Outreach work It is unlikely when working in an ACCHS that the whole week will be spent in the same office. Visits to “parkies” and “grass camps” (people living in town parks and fringe dwellings), sessions in jails, and visits to outlying communities are just some of the possible outreach scenarios. Quality improvement, population health and research programsThe futility of practising medicine only on an individual level quickly becomes apparent and, once an ACCHS doctor is established within a community, it is possible to branch out into quality improvement and population health programs. This requires working with the community and the myriad funding bodies to develop, for example, programs for Pap smear screening, smoking cessation or diabetes care. This not only benefits the community and enhances service capacity, but also allows GPs to develop skills that may prolong their involvement in Indigenous health. It is relatively common to conduct research in larger ACCHSs, and opportunities exist for GPs to access research funding and training. DifficultiesCultural safetyThere are two relevant aspects of cultural safety. The first is the more traditional view of cross-cultural communication;4 the second concerns the culture of being a doctor. In the ACCHS setting, doctors will often have a different cultural background to their patients, and English may not be the first language of the patient or the doctor. Consequently, cross-cultural training programs provide orientation in cultural background, language concepts, communication and relationships within the local Indigenous community. Cross-cultural education outlines the history of white colonisation of Australia, the effect of subsequent government policies on the local community, the cycle of poverty, local communication issues, and local customs for births, deaths and illness. Not all cultural awareness programs are alike, so, while education provides an important introduction, cultural awareness accumulates with experience, but only develops fully if the doctor is prepared to respect and learn from the community and, importantly, if the community will mentor and assist the doctor. The second aspect of cultural safety is the culture of medicine that many doctors are used to and have been trained in. This can cause difficulties coping with the unfamiliar clinic environment — its very high workloads, poor infrastructure, multiple and chaotic medical records, lack of structured clinical sessions with no appointment systems, patients arriving en masse in bussed transport, and apparently poor patient compliance (which often can be explained by difficult dosing regimens, and a lack of common reality and priorities). While these issues may appear insurmountable to a new GP, leadership and a quality improvement approach can result in more controlled working environments. Trauma and griefThe recent history of Queensland Aboriginal and Torres Strait Islander communities, like those in Townsville, is one of loss of land (often accompanied by violence), forced removal, and detention of differing clans in missions and reserves, with consequent loss of culture, autonomy, identity and life skills. Many patients come from such traumatised family backgrounds.5,6 Dealing constantly with traumatised patients and the resulting problems of unemployment, poor education, substance misuse and violence can become a threat to the wellbeing of the ACCHS staff, especially the GPs. The high mortality rates in Indigenous populations become starkly evident. In any context, it is difficult for GPs to see relatively young patients die of preventable diseases, but the monotonous regularity of community funerals can become depressing. Indigenous doctors, who may also be from the local community, can experience this from both a medical point of view as well as from family involvement. It is important that GPs are able to recognise their own reactions to trauma and grief and take appropriate action. While counselling is available, regular periods of leave are probably necessary for survival in the job. Lack of autonomyThe stressors of mainstream general practice — job demands, time pressures and perpetual change — are well known. These also affect GPs working for ACCHSs, but the strongest predictor of job satisfaction has been identified as being in control of the job.7 The major stress for GPs working for an ACCHS is the loss of autonomy in practice management. ACCHSs are governed by community-elected boards, who make many of the decisions GPs in mainstream practices would ordinarily make themselves. Some board members are highly trained in the health field, others are not, and their decisions may or may not be in line with GPs’ perceptions of how a medical clinic should operate. This lack of autonomy can make the implementation of change difficult when the ultimate decision for acquisition of equipment, recruitment, conference attendance, or participation in research and population health programs lies with the board. The stress is minimised if GPs enjoy good working relationships with their senior managers, chief executive officers and boards. Community politics may also influence some decisions, which can be difficult to comprehend until an understanding of the broader context of Indigenous control and empowerment has been gained. RemunerationWhile remuneration levels in some centres are improving, through support from, for example, the Rural Incentive Payments Scheme,8 GPs in the larger urban ACCHSs are often not as well paid as their mainstream colleagues. This reinforces the perception that the work they are engaging in is less valuable and has led to a high turnover of doctors and difficulty in attracting Australian-trained GPs. To attract and retain more Australian-trained doctors, a review of remuneration is needed. Career paths and ongoing trainingThe better supported ACCHSs are an ideal environment for training, not just in general practice, but also in specialties such as public health, general medicine and cardiology. This would provide a new source of doctors for the Indigenous community. The burden of disease encountered on a daily basis would, with remote supervision, provide excellent training for registrars. While there is growing support from the Royal Australian College of General Practitioners in cultural safety, peer networks and mentoring, in many areas GP registrars are not allocated to ACCHSs as a priority. If the Colleges could develop training paths that encompass terms in ACCHSs, it would not only enrich the pool of doctors trained in caring for Indigenous people, but also enhance the quality of medical care for Indigenous communities. Public health registrars, with their population health skills, could be a valuable asset to the larger ACCHSs. There have been some moves to offer integrated general practice and public health training, but this has left many GPs in the ACCHS sector faced with the decision of whether to stay or leave when they reach an advanced stage of their training. ConclusionWhile every GP will have a different experience within an ACCHS, a few will truly become part of the community. Many doctors will develop close friendships with both staff and families that can be especially rewarding. Sharing the highs and lows of the Indigenous community, especially with respect to sport and music and their role in mainstream Australian culture, strengthens the bonds some doctors have with their roles in ACCHSs.

Kathryn S Panaretto MB BS, MPH · Mark Wenitong BMed