A vision for the future of general practice
Presentation by Professor John Horvath, Chief Medical Officer, Australian Government Department of Health and Ageing, to General Practice Registrars Australia Workshop at Parliament House, Canberra.
Slide 1 – A Vision for the Future of General Practice
IntroductionGood afternoon and thank you for inviting me to speak to you today. I have been asked to speak to you on my, and the Department of Health and Ageing’s, priorities and vision for the future of general practice. Before I do, however, I would like to briefly reflect on where we’ve come from. It’s very difficult to illustrate a future without first reflecting on what has brought us to where we are now.
Slide 2 – Where we’ve come from
- There have been dramatic shifts in general practice in the last few decades.
- Even since the early nineties, GPs are now older, more likely to be female, much more likely to work part-time and work in a large practice1.
- There has also been a shift in the relationship between doctor and patient. The paternalism of yesteryear has receded to be replaced with a more patient centred approach.
- Consumer expectations for accountability and transparency from both health providers and government are at the fore. This has been accentuated by modern healthcare scandals, the Harold Shipman case in the UK and Dr Death in Australia are poignant examples.
- And I’m sure you can all remember the surprising ease with which your local pharmacist was able to decipher a seemingly meaningless scribble on your prescriptions – not anymore, the computer age has arrived.
- A lot has changed. However vocal lobbying by medical representatives has not and I hope never will. The first Australian qualified medical practitioner and first Australian teacher of medicine, William Redfern began this tradition. Sentenced to death for mutiny over poor conditions for patients on naval ships, he was given a reprieve and sent to Australia as a convict. One of the most popular doctors in the colony in his time, he had a strong concern for convict’s health and their emancipation. I am thankful that we still have many William Redferns in Australian medicine.
Slide 3 – An Affluent Australia – prevalence of risk factors
- The health system has undergone major reform in the past decade in primary care and general practice in particular.
- This has been due to a range of factors. On the supply side, doctors have been working shorter hours in order to meet family commitments and maintain work-life balance. While on the demand side a reduction in infection and injury, an affluent Australian lifestyle and an ageing population have dramatically moved the burden of disease from acute, episodic conditions to chronic disease. Chronic disease now accounts for around 80% of the burden of morbidity and mortality2.
Slide 4 – New Elements of Primary Care
- There are a number of elements of the primary care system that we have now that we didn’t exist 10-15 years ago.
- We now have targeted remuneration for general practice for chronic disease management, through GP management plans, team care arrangements and case conferencing Medicare items.
- The team care arrangements and case conferencing items allow for the patient’s doctor to coordinate and discuss the care of the patient with other relevant health providers.
- A little over two years ago the Government made the bold move to provide Medicare funding for services provided by Allied Health Workers. Patient’s on a team care arrangement can access allied health services, such as physiotherapy, psychology, occupational therapy and others, on referral from a GP.
- This frees up the GPs time enabling them to focus on more complex cases.
- Since 2004, there have been Medicare items for practice nurse services provided on behalf of a GP for services such as immunisations, wound management, cervical screening and antenatal care.
- There are also incentives for practices to employ practice nurses in rural and remote Australia and in outer urban areas of workforce pressure.
- These measures are hitting their target with a rapid increase in the number of nurses working in general practice. In the two years to December 2005 practice nurse numbers increased by almost a quarter to just under 5,0003.
- The proportion of practices employing practice nurses has jumped from 40 to 57 percent in the same timeframe.
- Late last year a new initiative was introduced that promotes a team approach to mental health care. It includes Medicare items for GPs to undertake early intervention, assessment and management of patients with mental disorders and Medicare funded referral to clinical psychologists and other allied mental health service providers.
- All of these initiatives recognise that, when it comes to chronic disease, no single health service provider can do it all.
- There is also an increasing focus on prevention, early detection and patient self management.
- Through a range of health check MBS items we are identifying patients at risk or in early stages of disease before their condition worsens and more intensive treatment is required.
- the Australian Primary Care Collaboratives Program has been bringing general practices together in peer-led workshops to improve the quality of patient care.
- The program has a strong emphasis on using practice-level data to show what proportion of patients are receiving best practice care and where care can be improved.
- About 500 general practices have participated in Collaboratives over the last four years and they have demonstrated impressive results. For example, over 18 months, practices recorded a 106 % improvement in the proportion of patients who, having had a recent heart attack, are on clinically appropriate medication.
- General practice has also been transformed by the information technology revolution. Eight years ago, less than 15% of GPs were using computers to help them perform what must be one of the most information intensive jobs in our economy.
- Now about 95% of GPs are using computers. The E-health transition is no easy process, but we are on our way.
Slide 5 – At the Centre of Primary Care
- Throughout this period of change, general practice has remained the centre of the primary care system. It is general practice that provides ongoing comprehensive care to individuals and families with about 85% of Australians seeing a GP at least annually4.
Slide 6 – Primary Care vs Health Care Expenditure
- There is evidence that countries with strong primary care systems achieve better and more equitable patient outcomes5. There is also evidence to demonstrate that countries with a greater primary care focus have more efficient overall health systems, with less per capita expenditure – an important point in the context of an ageing population.
Slide 7 – GP & Specialist full-time equivalent
- Between 2000 and 2004 the number of GPs relative to the Australian population dropped slightly while there was a slight increase for specialists.
- We expect this may change given the strong investment the Australian Government has been making in general practice in recent years. Currently a GP on average draws around $251,000 a year from the MBS – compared to around $197,000 in 2003.
Slide 8 – A Simpler Future
- The Australian Government has been busy with primary health care reform in the last decade. However, there is still more work to do to prepare us for the increased healthcare needs of an ageing and relatively affluent population.
- A simpler approach to health policy and system administration is required. In our effort to do lots of things we’ve complicated the landscape with 40 programs where we could have about 5.
- The number of medical representative groups has grown in line with this complexity. A rural GP could approach over a dozen professional groups to access training: their local Division, a Rural Workforce Agency, the Royal Australian College of GPs, a University Department of Rural Health and the list goes on.
- In the future the Department sees a simpler set of priorities for primary health care which include:
- First – careers in general practice and primary care would be attractive and viable. It goes without saying that we need to attract people to work in primary care and we need to be able to keep them there. We also need the right people in the right place working in teams. In this category of policy falls reward and incentives, appropriate training, satisfactory flexible work, and reduced red tape.
- Second – we need to further shift the emphasis from episodic and acute care to ongoing, holistic care with a strong focus on prevention. Prevention is better than cure. There are a number of risk factors for chronic disease, including smoking, physical inactivity, poor nutrition, overweight and obesity, alcohol misuse, that if addressed could limit the burden of chronic disease and keep people productive, healthy and happy.
- Third – Best practice would be easier practice. It is not in the Government’s interest to restrain best practice. We need to identify the systemic barriers to best practice. Why, for example, do only 30% of GPs ask their patients if they smoke when we know that messages from GPs about smoking really do have an impact.
- Fourth – we would have better systems of ensuring quality care and accountability for good health outcomes. Our greatest challenge is that we have very little idea about what goes on in primary care. The MBS is a payment system, not a data gathering system. It tells us a service has been provided, but not how or what that service was provided for. If we don’t know what happens – how can we fix the gap between actual practice and best practice? How do we know where to start? Shared electronic patient records are one answer and an investment in targeted research is another.
- And finally we need team based models of care which enable people to see the primary health care provider best placed to address their needs. This is about teams, allied health, state funded services and the lifestyle improvement sector such as gyms and community health initiatives.
Slide 9 – Better Use of the Primary Care Workforce
- As the workforce currently stands, we have waiting lists for specialists, we have waiting lists for surgeons, and waiting lists for GPs. And we often hear from nurse and allied health worker groups that they could be doing more.
- We need to better use the workforce we have by safely transferring tasks to those health care providers best placed to meet healthcare needs.
- Traditionally the primary care financing system has not supported the shifting of tasks or task transfer between health professionals. But this is quickly changing.
- The Australian Government’s practice nurse initiatives are a good example. Practice nurses enable a general practice to provide a wider range of services. They free up GPs time to focus on other patients and more challenging cases. They enhance general practice.
- Another good example of task transfer are the Medicare items for preparation and review of referred psychiatrist assessment and management plans. These items provide rebates for psychiatrists to prepare (or review) an assessment and management plan that is then carried out by the patient's GP. The GP provides the ongoing management of the patient rather than the psychiatrist.
- This task transfer is not new, but a common evolution in health care. In the hospital setting consultants and senior doctors were once responsible for managing and monitoring patients during dialysis. Now nurses and, in rural areas, Aboriginal Health Workers have responsibility for this job. Forty years ago nurses did not take blood and suture wounds in the emergency room. There was a time when they did not take blood pressure and now many patients monitor their own.
- In general practice we have just been slow to catch up.
- For example, Piterman and Koritas (2005) state that ‘specialists often inappropriately take on the role of providing continuity of care for chronic and stable conditions, for example hypertension, ischemic heart disease and non-insulin dependant diabetes’ diminishing the time available to them to see new patients.
- Cancer patients now live for years rather than weeks and heart disease patients live for decades rather than years. With good cooperation between professions and, where needed, support for GPs to develop the skills, GPs could be managing more of these patients beyond the acute stage of their condition.
- A number of specialist colleges have been cooperative and supportive in the development of training for GPs. The Diploma of Obstetrics, which enables GPs to provide obstetric services in rural hospitals and Psychiatry training for GPs are both good examples6.
Slide 10 - Conclusion
- Very little of what I’ve outlined today about the challenges facing our health system and potential strategies to address them is new – it’s been said before.
- A number of recent fora have provided the opportunity for many of these issues to be debated, including the development of the National Chronic Disease Strategy, the Productivity Commission report on the health workforce and recently a Medical Journal of Australia issue dedicated to task transfer (all released in the last 18 months)7.
- The idea of task transfer has gained some qualified support from the peak medical bodies including the Royal Australian College of Physicians, Royal Australian College of Surgeons and the Australian Medical Association.
- Cautions about safety, clear definition about roles and responsibilities, maintaining patient trust and the integrity of the basic principles of general practice (including patient centeredness, continuity of care, comprehensiveness) are loud and clear.
- We seem pretty clear on what the issues are and willing to come together to discuss them – today is a case in point.
- I thankyou for this opportunity, and look forward to our discussion today to further this dialogue and work towards a vision of a bright future for general practice.
1. Charles, J. et al (2004) The evolution of the general practice workforce in Australia, 1991-2003, Medical Journal of Australia, 181 (2) (p85-90)
2. National Health Priority Action Council (2006) National Chronic Disease Strategy, Australian Government Department of Health and Ageing, Canberra
3. Australian Divisions of General Practice (2006) National Practice Nurse Workforce Survey Report
4. (2007) BEACH – General practice activity in Australia 2005-06, University of Sydney and AIHW
5. Starfield B. et al (2005) Contribution of Primary Care to Health Systems and Health, The Milbank Quarterly, Vol. 83, No 3 (p 457-502)
6. Piterman, L. and Koritsas, S. (2005) Part I. General practitioner-specialist referral process, Internal Medicine Journal 2005; Vol. 35 (p430-434)
7. (July 2006) Medical Journal of Australia, 185 (1)
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