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General Practice in Primary Health Care - 2016

12 Jan 2017

1. Introduction

Primary health care (PHC) is the front line of the health care system and usually the first level of contact of individuals, the family and community with the national health system. It is scientifically sound, universally accessible and constitutes the basis for a continuing health care process. It provides comprehensive, coordinated and ongoing care by a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systems. Primary health care includes community development, health promotion, patient advocacy, illness prevention, and treatment and care of the sick (including supportive management of chronic disease, palliative and end of life care, and rehabilitation). [1][2][3]

Primary health care services are delivered in settings such as general practices, community health centres, aboriginal community controlled health centres, and allied health practices. Importantly, PHC supports and educates people in the community to better manage their chronic health conditions, improving their quality of life and reducing their risks of disease progression and complications.

General practice is the cornerstone of successful primary health care, which underpins population health outcomes and is key to ensuring we have a high-quality, equitable and sustainable health system into the future. General Practitioners (GPs) are registered specialists in the discipline of general practice recognised by the Australian Health Practitioner Regulation Agency. Practices in which GPs spend less than half of patient contact hours providing general practice care, as defined by the Royal Australian College of General Practitioners (RACGP), are considered special interest clinics rather than general practices.

The primary health care system has four main purposes:[4]

To provide the right care at the right time, at the right place, ensuring a healthier population;

  • To provide cost-effective, community-based care, and in doing so appropriately minimise hospital-based care;
  • To act as both an enabler and gateway to other services to ensure they are provided in a timely way but only when needed; and
  • To coordinate care between different health providers and different parts of the health care system, ensuring a seamless, integrated, effective experience for the patient and minimising costly fragmentation, duplication or gaps in care.

General practice provides primary, continuing, comprehensive and co-ordinated, culturally sensitive, inter-generational holistic health care to individuals and families in their communities. It is underpinned by rigorous scientific medical training and the ability to apply the evidence appropriately in community settings. All these elements place general practice at the centre of an effective primary health care system.

Quality general practice adopts the Quadruple Aim framework[5], an approach to optimising health system performance by:

    1. pursuing improvements in population health, primarily through
    2. enhancing the patient experience of care, and
    3. reducing the per capita cost to the health care system.
    4. Improving the work life of health care providers is crucial in the achievement of the first three aims.

This Position Statement examines the role of general practice in the delivery of primary health care services in Australia. The AMA has developed this Position Statement as a vision for general practice and primary care into the future.

2. The Value of General Practice in Primary Health Care

General practice is pivotal to the success of PHC in Australia. The World Organisation of Family Doctors supports this view. In a 1991 statement titled The Role of the GP/Family Physician in Health Care Systems, general practice was described as the "central discipline of medicine around which medical and allied health disciplines are arranged to form a cooperative team for the benefit of the individual, the family and the community."[6] This remains the case today.

The World Health Organization has found that the populations in those countries with strong general practice have:[7]

  • Lower all cause morbidity (lower rates of ill-health) and mortality
  • Better access to care by all members of the community
  • Lower rates of people being readmitted to hospital after treatment
  • Fewer consultations with consultant specialists
  • Less use of emergency services [8]
  • Better detection of adverse effects of medication interventions.

In their crucial role as the first medical contact and in provision of ongoing health management, GPs have a profound influence on both health outcomes and health expenditures. It is estimated that primary health care professionals control or influence approximately 80 per cent of health care costs, which means that they have an important role to play in ensuring that health expenditure remains sustainable.[9]

The role of the GP is increasingly important as the population ages and the increases in the burden of chronic disease require continuing long-term care. A primary care system that is adequately funded ensures value for money by providing patients with the right care at the right time, in the community, thereby reducing costly preventable hospital admissions.

3. Key elements of high quality and sustainable general practice

3.1 Access for patients

The AMA supports a primary health care system that provides equity of access to quality care for all Australians regardless of their race, sex, age, religion, socioeconomic status or location. Good access includes affordability, the availability of appointments, timeliness of care, including in the after-hours period, and the ability to access the GP of the patient’s choice. Equitable access cannot be achieved unless it is underpinned by an adequate, appropriately trained workforce.

Some population groups in Australia experience marked health inequalities compared with the general population. These groups include Indigenous Australians, people living in rural and remote areas, people with low socioeconomic status, people in custody, and people with disability.[10] It is essential that evidence-based Government policy and adequate resources are applied to cater to the unique needs of these groups to ensure they receive timely, comprehensive, and quality health care.

To minimise social and cultural barriers to healthcare and reduce inequalities, primary health care providers and organisations should have access to initiatives, training and resources, including interpreter services, which support them to deliver culturally competent health care that is responsive to Australia’s culturally and linguistically diverse communities.

3.2 Funding

Commonwealth Government funding for general practice services currently stands at around 8 per cent of total government health expenditure[11]. This represents a modest investment that is delivering excellent outcomes for most patients. While the Commonwealth is the dominant funder of general practice services, patients also make a contribution of around 6.5 per cent of total general practice costs. The AMA supports the concept that those patients that can afford to do so should make some contribution to the costs of the GP care that they receive, provided appropriate safety nets exist to protect vulnerable groups from out of pocket costs to ensure that these do not become a barrier to care.

Funding for general practice services in Australia is based on a blended model of funding, although the predominant funding model is fee-for-service (FFS). FFS has proven to be an effective funding model over many years and should remain the primary source of funding for general practice services. It works effectively for the majority of patients, providing autonomy and choice, as well as access to care based on clinical need.

There is significant scope to build on the blended funding arrangements, particularly in tackling chronic and complex disease, which requires comprehensive, integrated and well coordinated care. A blended model may include practice and service incentives, funding for preventive health care or enhanced care for chronic disease patients, infrastructure grants, and quality improvement measures.

Funding goal

GPs are managing more problems in each consultation than they did a decade ago as patients, particularly older patients, present with multiple reasons for the encounter. GPs are also spending more time with patients and manage the vast majority of the problems presented to them[12]. With Australia’s growing and ageing population, this trend is set to continue. Yet funding for general practice is not growing in keeping with this trend. The combined forces of rising demand and diminishing funding will have a significant impact on the quality of care practices are able to provide.

To ensure that general practice is equipped to meet these challenges, the Commonwealth needs to deliver real resources to frontline GP services. Whereas spending on general practice services represents around 8 per cent of total Government spending on health and this proportion has remained relatively stable despite a growing workload, this figure should be lifted over time to around 10 per cent as part of an effort to re-orientate the health system to focus more on general practice, with long term savings to the health system anticipated in return.

 3.3 A regular GP and the Medical Home

There is inherent value in the continuity of care provided by a patient’s regular GP and/or general practice, when compared to the cost of care that is fragmented among different health care providers. Fragmentation is associated with increased costs of care, a higher chance of a departure from clinical best practice, and higher rates of preventable hospitalisations.[13]

Having a regular GP and/or general practice enables the long-term and continuous care of a patient through an ongoing relationship of respect and trust. A regular GP becomes familiar with a patient’s medical history and their family’s medical history and, through the trusted relationship, can effectively advise patients on the risks to their health and the factors in their lives that contribute to those risks, including unhealthy lifestyle choices such as excessive alcohol consumption, smoking and poor diet.

A regular GP can also provide ongoing management of risk factors, coordinate allied health services, and deliver other preventive health care measures such as vaccinations and screening tests. Another important role for the regular GP is to assist patients in navigating an increasingly complex and confusing health and welfare system.

The medical home refers to a model of primary care that is patient-centred, comprehensive, team-based, coordinated, accessible, equitable, and focused on quality and safety.[14] General practice is the logical and natural location for the medical home. The vast majority of Australians routinely attend the same general practice and most of them always choose to see the same GP.[15]

An adequately resourced medical home model of general practice can support quality primary care, particularly the provision of services outside of the patient consultation. It can better enable well targeted, well-coordinated multi-disciplinary care for patients with chronic and complex diseases. Adoption of this model in the US and other countries has resulted in improved quality measures, performance and service use, with a highly significant reduction in avoidable hospital admissions, emergency department use and overall care costs.[16][17]

The AMA Position Statement on the Medical Home -2015 outlines the key principles by which a Medical Home can provide benefits and improve patient care. It can be found at https://ama.com.au/position-statement/ama-position-statement-medical-home.

The AMA Position Statement Doctors and Preventative Care 2010 can be found at https://ama.com.au/position-statement/doctors-and-preventative-care-2010.

3.4 A well trained and appropriately distributed workforce

General practice is the centre of primary care and Australia must work towards a training system that produces sufficient new GPs each year to meet the needs of the community, whilst maintaining a high quality of training and clinical care.

Future workforce demand, supply and equitable distribution should be addressed by appropriate government policies based on data provided by an independent workforce planning agency that is adequately resourced and supported to undertake comprehensive workforce modelling.

Maintaining profession-led governance and training structures that support a strong vocational training experience is essential to preserving the integrity, accessibility, and quality of general practice training.

The 2016 AMA Vision Statement for General Practice Training can be found at https://ama.com.au/article/ama-vision-statement-general-practice-training-2016-0.

3.5 Team based care

An effective way to deliver quality care is through GP led multidisciplinary care teams. Planned multidisciplinary team-based care has been demonstrated to improve outcomes in patients with chronic disease, in primary care.[18] Multidisciplinary team care involves professionals from a range of disciplines working together to deliver comprehensive care that addresses as many of the patient’s needs as possible. The team can be comprised of professionals working within a single organisation, such as a general practice, or professionals working together from a range of organisations. The composition of the team may change over time, in response to the changing needs of the patient.

For a team care approach to be both clinically and cost effective, patients require a medical diagnosis, clarity of clinical needs, and appropriate and well-coordinated care. This avoids inappropriate or delayed treatment, fragmentation of care, unnecessary duplication of services and wastage of health care resources. The structure of the MBS must allow GPs to delegate activities to the most appropriate member of the primary care team while maintaining responsibility for supervising and managing total patient care.

3.6 High level coordination

The AMA supports the concept of an overarching structure of primary health care organisations (PHCO) to improve the integration of health services within primary health care, and enhance the interface between primary care and hospital settings. PHCOs can help to ensure that health care services are tailored to the needs of local communities and can have a positive impact on aged care services, palliative care, mental health outcomes, after hours services, chronic disease management, indigenous health services and services for the disadvantaged[19].

PHCOs should have a strong focus on supporting general practice and building general practice capacity. They should also focus on population health and engaging with Local Hospital Networks or Districts to ensure continuity of care. General practice must be central to PHCOs, and GPs must be heavily involved in their leadership and management.

The AMA Position Statement Primary Health Networks 2015, at https://ama.com.au/position-statement/primary-health-networks, outlines the key principles for successful PHCOs.

3.7 Commitment to quality and safety

Every member of the primary care team must practise according to the principles of evidence based medicine (EBM). In addition, they should practise according to profession-set standards, be appropriately registered and undertake continuing professional development.

The AMA supports an EBM approach, which entails the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients within the general practice setting.[20] Clinical guidelines based on EBM should not be used to prescribe interventions but should augment clinical skills and experience.

Collaborative clinical care pathways support best practice, evidence-based decision making, improve the continuity of patient care between primary, community and hospital care settings and improve patient outcomes.

GPs work to a very high level of standards that have been developed by the profession and the majority of general practices are accredited. This demonstrates strong commitment to providing safe, quality care to patients, as the quality of Australia's health care is partly dependent on the structure and organisation of practices.

The AMA supports a system of general practice accreditation that is independent of Government, is under the effective control of actively practising GPs, and is a voluntary, educational process encouraging a culture of continuous quality improvement. It must not be overly onerous, disruptive or costly to undertake.

Continuing Professional Development (CPD) helps GPs update and maintain their skills and knowledge, particularly as new evidence from rigorous research mandates changes to standard practice. The AMA supports CPD, which is integral to the definition of medical professionalism.

3.8 Research

General practice is a distinct medical specialty and requires its own specific research. Findings from other medical research cannot simply be transferred to general practice. Traditionally, there has been limited research into general practice specific fields. This must change.

Research improves patient care, is important for teachers of general practice and stimulates intellectual rigour and critical thinking.[21] It is the missing link in the development of high quality, evidence based health care for populations.[22]

More support must be provided to general practice research in order to improve primary care and patient health outcomes. In particular, GPs should be supported to undertake research. There must also be adequate support for translational research in the general practice environment in order to implement evidence based medical advances cost effectively and sustainably.

A robust general practice research discipline will provide GPs with new, exciting opportunities to explore their field of practice and produce cutting-edge findings and innovative models of care that will assist the profession improve the services it provides.

Around 2 per cent of National Health and Medical Research Council (NHMRC) grants are directed to supporting primary care research [23], including general practice. This funding is woefully inadequate and is well below the contribution of general practice and primary care in the context of the broader health system.

The AMA believes that general practice and primary care deserves a much fairer distribution of NHMRC funding and calls for a dedicated stream of funding for general practice research in the order of 8 per cent of its grants budget, commensurate with the contribution of general practice to the Australian health system. This funding must be backed by the establishment of a national centre of excellence in general practice and primary care research.

References:

[1] Australian Primary Health Care Research Institute, Australian National University. Fromhttp://aphcri.anu.edu.au/about-us/what-primary-health-care (Accessed 13 May 2016)

[3] World Health Organization’s Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978.

[4] McKinsey & Company, How can Australia improve its primary health care system to better deal with chronic disease? Background paper for Australian Department of Health, 2015.

[5] Bodenheimer, T and Sinsky, C From Tiple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Annals of Family Medicine vol.12 no. 6 573-576, Nov/Dec 2014

[6] The Role of the General Practitioner/Family Physician in Health Care Systems: A Statement from WONCA, 1991

[7] World Health Organization, The world health report 2008: Primary health care now more than ever, WHO, Geneva, 2008.

[8] O’Malley AS, After-hours access to primary care practices linked to lower emergency department use and less unmet medical need. Health Aff (Millwood), 2013. 32(1): p.111

[9] McKinsey & Company, How can Australia improve its primary health care system to better deal with chronic disease? Background paper for Australian Department of Health, 2015.

[10] Australian Institute of Health and Welfare, Australia’s Health 2014

[11] AIHW Health Expenditure Australia 2013-14.Table A6 p77

[12] Britt H, et al, General practice activity in Australia 2014–15. Sydney University Press, November 2015

[13] Frandsen B, et al, Care fragmentation, quality, and costs among chronically ill patients, Am J Manag Care. 2015: 21(5):355-362

[14] Patient-Centred Primary Care Collaboratives. Defining the medical home: A patient-centred philosophy that drives primary care excellence. https://www.pcpcc.org/about/medical-home

[15] The Menzies-Nous Australian Health Survey 2012

[16] Jackson, C. L. (2012) Australian general practice: primed for the “patient-centred medical home”? Med. J. Aust. 2012, 197(7): 365-366

[17] Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N; Osborn; Doty; Bishop; Peugh; Murukutla (2007). "Toward higher-performance health systems: adults' health care experiences in seven countries, 2007". Health Affairs 26 (6): w717–34

[18] Harris, M.F. et al Multidisciplinary team care arrangements in the management of patients with chronic disease in Australian general practice. MJA 2011; 194: 236-239

[19] AMA Position Statement Primary Health Networks 2015

[20] Evidence Based Medicine: What it is and what it isn't. Sackett DL, Rosenberg WMC, Gray JAM et al. Brit Med J 1996 312:71-72

[21] Ms D.Askew, Professor C Del Mar, Professor B McAvoy, Professor D Lyle General Practice Research, General Practice in Australia 2004

[22] Rosser, Walter W, van Weel, Chris (2004) Research in family/general practice is essential for improving health globally, in Annals of Family Medicine Vol 2 Supplement 2 May/June

[23] McIntyre EL, Mazza D, Harris NP. NHMRC funding for primary health care research, 2000–2008. Med J Aust 2011; 195: 230.


Published: 12 Jan 2017