General practice

Matthew Samarin

How we fund our health system to achieve the most effective, efficient and equitable outcomes is high on the political agenda. Australia has just experienced a federal election dubbed “the health election” for one of the largest funding boosts to Medicare promised by both major parties.1 This issue of the MJA is dedicated to general practice — the bedrock of the health system that has arguably been in crisis for several years. A centrepiece of Labor's campaign on health was a pledge to build more bulk‐billing urgent care centres around the country. These centres aim to bridge the gap for urgent illnesses when patients cannot see their general practitioner and reduce pressure on emergency departments (EDs).2 In this issue of the MJA, Savira and colleagues3 conducted a scoping review to examine the effectiveness of urgent care centres. They examined studies conducted in clinics in the UK, Europe and the United States and found that the results with respect to reduction in ED visits were mixed. While some studies reported that the introduction of these clinics was associated with a reduction in ED visits, others often showed no changes or an increase in presentation to ED minor injury units. Importantly, most studies examined showed a reduction in hospital admission rates in places where urgent care clinics had been set up. Although most patients in consumer surveys examined were happy with the service, continuity of care was a concern expressed by both patients and practitioners. Even though the review was limited by the high heterogeneity of methodologies examined, it provides a warning about relying on a model without adequate governance and formal assessment of cost effectiveness. Indeed, a recent interim report by the Department of Health and Aged Care found that although the cost of seeing a doctor in an urgent care clinic is lower than in an emergency department, this cost is at least five times that of seeing a general practitioner for a standard consult.4 Continuity of care has been an ongoing issue in primary health care for several years. Unlike the UK and New Zealand, where patients are often enrolled into their local primary care clinics for care, in Australia most people can visit any general practitioner anywhere for care, which often leads to a significant amount of fragmentation of care and over ordering of investigations.5 The MyMedicare initiative that has been recently rolled out in Australia attempts to correct this. Bates and colleagues6 in their scoping review for this issue examined enrolment models in other countries to elucidate their impacts on continuity of care. They found little evidence that enrolment improved continuity of care; however, study populations had high levels of pre‐existing patient engagement with a usual general practitioner The review provided evidence that enrolment can be used to support other primary care reforms such as preventive care and management of chronic conditions, and demonstrated how other reforms, such as incentives or increased access to services, can affect uptake of enrolment. For MyMedicare to work, practices and patients need to see value in enrolment. This value proposition will be hard to make without more targeted research evaluating, and then demonstrating, the benefits of enrolment, not just for individuals who have a usual general practitioner, but for those who do not. Although the review noted that the MyMedicare scheme currently has limited incentives for patients, there have been proposals to tie in funding for chronic care plans and allied health visits to a patient's nominated general practitioner and practice on MyMedicare.7 This will likely pressure general clinics to enrol patients specifically to their clinics. The overarching problem most general practitioners have with investment in primary care is that often the governments do not seem to want to consult with them with regards to their experiences and opinions on how unprecedented levels of Medicare funding might best suit their patients. Most clinics currently run on the slimmest of margins and the bulk‐billing incentive still does not meet the gap that mixed billing currently provides most clinics.8 Without effective primary care most Australians will be left without adequate health care. A substantial proportion of research needs to be carried out on effective models of care focusing on general practitioners with general practitioners as a core part of the research and assessment team.

Aajuli Shukla

Recently, my partner and I have been trying to relate some of the disciplining that we do as a family with our almost 3‐year‐old child back to respect: for boundaries, for feelings and for our elders. The two of us have also been reflecting on what respect means to us currently within our profession between various specialties. In this issue of the MJA focusing on general practice, Suetani and colleagues (https://doi.org/10.5694/mja2.52281) make a compelling case for a drastic change in the way mental health care is organised in Australia which requires a respectful collaboration between specialties. They write that increased funding will not necessarily improve mental health care provision, nor will it be particularly efficient without a greater inclusion of the biopsychosocial model in the way mental health is managed. Most general practitioners are currently shouldering the cost of complex mental health care, especially in socially and economically disadvantaged groups without adequate support or funding. Care is often fragmented and lacks a more holistic approach. They argue that a comprehensive approach with adequate inclusion of non‐mental health care workers to help manage some of the socio‐economic inequities that underscore mental health conditions and improve cohesion between the providers of mental health care is likely to yield better value. Primary care is an integral part of health care provision in Australia. Despite recent fragmentation of care with an increasing scope for pharmacists to prescribe antibiotics for urinary tract infections and the advent of urgent care centres, GPs continue to be important in the diagnosis and management of acute conditions in undifferentiated patients as well as screening for and managing a comprehensive list of chronic conditions. In their perspective article, Venning and colleagues (https://doi.org/10.5694/mja2.52287) acknowledge the difficult work that GPs do in trying to diagnose cancer in an undifferentiated patient. In highlighting the Australian Cancer Plan, unveiled in November 2023, which emphasised a strategic commitment to “maximising cancer prevention and early detection,” they acknowledge that currently “no cancer risk assessment tools are in mainstream use in Australian general practice”. They discuss various prediction tools in use and being trialled in Australia as an exciting addition to assist GPs in their day‐to‐day workflow. In a research article, Cameron and colleagues (https://doi.org/10.5694/mja2.52288) examine dysmenorrhea in adolescents, an oft encountered issue in primary care. Using data collected from 1600 adolescents in the Longitudinal Study of Australian Children (LSAC), they have shown an incredibly high prevalence of dysmenorrhea in young Australian adolescents that directly correlates to missed days of school and sports or extracurricular activities. An accompanying editorial by Grover and colleagues (https://doi.org/10.5694/mja2.52290) highlights the need for primary care physicians to recognise and ask about pelvic pain in young female adolescents while also discussing some management strategies. The most important take‐home message seems to be that too many health professionals normalise dysmenorrhea without considering its impact on daily activities. It has become rare as an editor of the MJA who also works as a GP to see research that focuses on the good that GPs do. Most research manuscripts conclude that primary care physicians need better training in or need better funding to perform an intervention. In this issue, a research letter by Albarqouni and colleagues (https://doi.org/10.5694/mja2.52285) illustrates the positive effect of GP intervention. They examined data collected by the 2020–21 National Health Survey and specifically looked at questions around consumption of alcohol, smoking and dietary habits. The team found that although a small proportion of respondents received advice regarding unhealthy levels of drinking alcohol, smoking and poor intake of fruits and vegetables, the proportion who changed their behaviours over time were more likely to have received advice from a GP regarding their habits compared with those who did not. It was heartening to see the power that general practice potentially has in changing behaviours that have a direct impact on the development of chronic disease. As a GP, respect that GPs get from the government feels lacking. The waning respect and renumeration across the profession are reflected in a significant decrease in training numbers of medical graduates choosing primary care as a career. In their research article, Sturman and colleagues (https://doi.org/10.5694/mja2.52291) perform a qualitative analysis with various stakeholders at different levels of general practice training to provide insight into this complex problem. They provide four recommendations: increasing medical student and junior doctor placements in general practice, increasing exposure to inspiring GP clinicians and educators, improving trainee pay and entitlements, and improving integration care and interprofessional relationships between hospitals and general practice clinics. Although intuitively these suggestions should go far to address the burnout and exhaustion evident in the primary care workforce, it feels like none of this would work unless primary care in Australia receives the respect it deserves from governing bodies. The participants in this study, most of them GPs, express their ongoing passion for the profession despite the challenges involved. One quote that was particularly poignant was of a participant talking about “saving the profession we love”. Current workforce projections already talk about a shortfall of GPs with regards to our rapidly ageing population. The problem is that without adequate funding, that comes from respecting the role GPs play in managing chronic disease, most of the solutions for primary care provision seem to focus on fragmenting care to other professionals rather than the resource we have at hand: a group of dedicated, incredibly well educated, and professional doctors that see anyone and everyone walking through their clinic doors.

Aajuli Shukla