AMA - Speech

As some of you may know, I’m a general practitioner who runs a long-established, but modern, medical practice.

In my practice, doctors, nurses and allied health professionals work collaboratively for the best patient outcomes.

The way I run my practice is logical and works well for both patients and staff.

To me, the way we run our practices is not all that different from what I hear the government asking for.

So I must confess I’m not really sure what all the fuss is about - why is there so much angst about primary health care reform?

To put it simply, GPs want reforms that will ensure a sustainable GP workforce, to ensure all Australians have access to quality medical care when and where they need it.

A GP workforce that is assisted by nurses and allied health providers in delivering quality team-based and coordinated patient care.

A workforce acknowledged for the vital role it plays in promoting better health and facilitating access to appropriate care.

A workforce not confined by bureaucratic red tape, prescriptive policies, or commercial interests as it strives to provide quality patient care.

At the same time, it appears Government wants to ensure universal access to medical care;

to encourage multidisciplinary team-based care and support the role that GPs play in the health care team;

But it seems a failure in communication – a misinterpretation of intent and effect – has resulted in an environment of turmoil, confusion, misunderstanding and frustration.

I hope in speaking with you today that I can impart to you – the politicians, the policy advisers, and the stakeholder representatives – a clear understanding of primary health care from the primary health care physician’s point of view.

I’m here today to share that knowledge with you – to help you understand what changes and support patients need, to ensure they continue to have access to quality, affordable health services.

I believe doctors and the government can work together to achieve this common goal.

So to begin this process of clear communication, let’s first make sure we’re working from the same definition of primary health care.

Primary health care, as defined by the World Health Organisation, is curative treatment given by the first contact provider along with promotional, preventative and rehabilitative services provided by multi-disciplinary teams of health care professionals working collaboratively.

Primary health care includes health promotion, illness prevention, care of the sick, advocacy, and community development.

Primary health care is the foundation – the heart – of any health care system.

In Australia, general practitioners are integral to the successful delivery of all the elements of primary health care.

In this country, the GP is the only clinician who operates in the World Health Organization’s nine levels of care:

With that in mind, I’d now like to examine some of the major pressures on primary care in Australia today.

It’s essential that any reform to primary health care be done properly from the outset, as the pressures on the front end of Australia’s health system are only going to grow over time.

There are a number of major issues in today’s medical environment that either impact now, or will impact in the future, on the delivery and accessibility of primary health care.

The reason we hear so much about it is because its impacts are debilitating not only to patients but to medical expenditure and the health system overall.

The World Health Organisation projects that in high-income countries, including Australia; deaths from chronic disease will increase by 11 per cent within the next 10 years.

According to the Australian Institute of Health and Welfare’s report, Australia’s Health 2008, almost three-quarters of deaths among people under 75 years are considered to be largely avoidable.

Where it is too late to prevent a chronic disease, better management can prevent the disease from progressing, reducing the need for more costly medical interventions.

The World Health Organisation believes we should be able to prevent at least 80 per cent of premature heart disease, stroke, and type 2 diabetes, and 40 per cent of cancer.

Prevention is achieved through interventions that encourage patients to establish a healthy diet, undertake regular physical activity, and avoid tobacco products and other harmful substances.

The challenge, of course, is to ensure that as people age, they maintain a good quality of life.

The longer we live, the more likely we are to develop a chronic disease - or two - and the longer we will have to treat and manage that chronic disease, or diseases.

The proportion of Australian GPs aged 55 years and over was 16 per cent in 2006, compared with 12 per cent in 2001[1].

The proportion of older GPs will increase significantly again in the next ten years as the baby-boomers reach retirement age.

Australia will have to keep older GPs in the workforce for as long as possible if we are to continue to provide access to quality primary care, and, importantly, if we are to have the capacity to train the next generation of GPs.

The government does little to attract Generation Y medical students to general practice.

The financial and time costs of red tape are a major disincentive to would-be GPs.

Other put-offs include the financial inflexibilities of owning a practice; the associated long hours; community expectations of discounted medical care; and misconceptions about general practice itself.

To compound the difficulty in attracting medical school graduates to general practice, students these days are much more in-tune with the need for an appropriate work/life balance than my generation ever was.

They know Australia needs them, and they want to dictate their own lifestyle and flexible working practices.

They want to be able to train part-time if it suits them to do so – to fit their training in around starting a family, for example.

They don’t want to be working unsafe hours – to be regularly on-call or working after-hours.

They want a career that allows for a lifestyle that includes time to spend with family and friends.

From what I’m hearing, the majority of Generation Y doesn’t want to be financially committed to their own practice – they want to be able walk in and out of practice as required.

When choosing their medical vocation they look for fields that will stimulate them – and they consciously consider the training requirements and the end dividend – that is, the impact on their lifestyle[2].

To ensure a sustainable GP workforce, GP recruitment, training and retention must be a primary consideration in any reform package.

The Government must immediately provide funding for additional GP training places.

The former Australian Medical Workforce Advisory Committee recommended that the number of GP workforce entrants should be between 1,105 to 1,200 per year.

In the current round, GPET has only been able to offer 600 places despite having 725 applicants.

In addition, there must be increased support for medical student placements in general practice, as well as for an increased number of pre-vocational trainee placements.

General practice training opportunities and incentives must be enhanced so that more new medical graduates are motivated to enter general practice in coming years.

On the flipside, there must be incentives to support existing GPs in becoming GP trainers, mentors and supervisors, and funding for infrastructure to support GP training.

In looking for more flexible ways of training GPs, the government should consider a greater role for GPs within public hospital systems.

As visiting medical officers, GPs could help improve the efficiency of the public hospital system, help to strengthen relationships with other specialists, and improve patient care.

GP visiting medical officers could also provide another avenue for medical trainees to experience the work of general practice.

The need to boost training for the GPs of the future is made even more acute by the working environment that exists for Australian doctors today.

I’m talking about a medical workforce under immense pressure, its numbers eroded by misguided government policies of the past.

This last decision, in particular, reduces GPs’ ability to maintain their procedural skills or causes them to relocate.

Sadly, rural and regional communities often have a very difficult time indeed trying to replace GPs who move away.

When a doctor is forced to leave a community, not only does it restrict access to medical care for the people who live in the community, but it also reduces rural areas’ capacity to train young doctors, and removes the opportunity for trainees to obtain valuable exposure to rural and remote practice.

Rural and remote areas – and, more recently, even outer metropolitan areas – have long experienced difficulties in finding GPs to live and work in their communities.

Recent incentives to encourage more GPs to practice in rural and remote areas do seem to be having a positive effect[3]– but if you talk to GPs on the ground they will tell you time and time again how they have spent a fortune over an extended period of time advertising for GPs to join their practice, to no avail.

The Australian newspaper recently reported that despite a growth in population the number of GPs in the Central Sydney division had fallen from 680 in 1995-96 to 590 in 2004-2005 with the number of services provided falling from 2.7 million to 2.4 million[4].

Increasingly we hear reports of general practices closing their books to new patients – because they simply do not have the capacity to take on any increase in workload and still be able to provide quality care to their existing patients.

There are other pressures putting the squeeze on our busy and hard-working doctors.

Despite figures, which indicate that the number of practising GPs is growing, the hours they work have decreased – still an average of 45 hours per week mind you – and with the increase in population the supply of full time equivalent GPs between 1997 and 2005 declined from 108 to 98 per 100,000 populations[5].

With increasing numbers of GPs working part-time, patients may not always be able to see their doctor of choice when they want – and this may be regarded as a lack of access - but most can obtain an appointment on the day they want if they are willing to see another GP within the practice.

We can’t discuss the pressures on primary care provision without addressing the pressures on Australian hospitals.

It’s not uncommon for patients at emergency departments to have to wait for half a day or more before a doctor sees them.

Meanwhile, the median waiting time for elective surgery has steadily increased from 27 days in 2001-02 to 32 days in 2005-06[6].

Increased delays in surgery waiting times add to the workload demands on GPs, as patients who are waiting for surgery need GPs to manage their conditions in the interim.

Patients who give up in frustration after waiting for hours on end at a hospital emergency department come to the GP with a condition that is exacerbated by their inability to access timely emergency care.

Each facet of the health system complements the other – and it is necessary to relieve pressures on both ends to benefit the system as a whole.

Through its various commissions and taskforces, the new government is of course examining what improvements might be made to the system.

The government will play an important role in developing and delivering primary health care policy into the future.

That is why it is so important that Health Minister Nicola Roxon and her Cabinet colleagues are well advised and have a clear understanding about how to ensure better access to and sustainability of quality primary health care.

They must also have a thorough understanding of the threats that may undermine this goal.

Failure to understand the issues at hand and a misguided rush to try and address them, could threaten the delivery and quality of primary health care though dangers such as fragmentation of care, reduction of standards and prescriptive practices.

With any change of Government, there is necessarily an adjustment period for stakeholders – adjustment in understanding their priorities – their style – and adjustment in how to effectively communicate advice.

The Government is proactive – they want to understand the issues and possible solutions – hence the summits, taskforces, commissions and committees.

They want to facilitate improvements – and they want to make changes to the health system that will ensure families can get the health care they need.

We in the medical profession must help them to figure out what is needed for the health care system into the future and how best to secure it.

The Government must be careful that it does not get carried away in its eagerness to implement reform.

One of the key dangers to the current primary health care system is change for change’s sake.

There is no doubt a great temptation for government to be seen to be doing something about improving patient access to health care.

In the health system, as in medical practice, any proposed change must be shown by the evidence to be of benefit to the patient, and cost-effective to the system.

It should not be a case of doing something – anything – because that is seen to be better than doing nothing.

Unfortunately, in the primary care arena there is not a lot of funding for research, and therefore the evidence can be somewhat thin on the ground.

More research will help to improve clinical practice and provide an evidence base to improve the delivery of primary care services.

A system underpinned by general practice already embracing the benefits team-based care provides to patients.

Our general practices have extended the role of practice nurses and developed appropriate working arrangements with allied health providers.

The AMA believes the most effective way to deliver quality primary health care is through a multi-disciplinary team approach – in much the same way as my practice already operates.

A team approach allows patients to access care from all the health professionals they need, to address their individual health concerns.

Primary health care teams ordinarily consist of medical professionals – that is, GPs and specialists – and non-medical providers, such as general practice and community nurses, dieticians, podiatrists, psychologists, physiotherapists, and so on.

But to ensure care is appropriately provided and coordinated there must be a team leader.

The GP is the only medical professional with the skills to provide comprehensive and holistic care.

Only the GP, who takes overall responsibility for the care of patients, and with whom the patient has a trusting relationship, is best placed to provide patients with guidance, advice and coordination through all stages of their care and treatment.

GPs formally train in medicine for between 11– and 14 years – and we continue to update our training throughout our careers.

It is the GP’s role to assess the patient, make a diagnosis, and determine the best management plan for that patient, including how best to manage utilise other members of the multi-disciplinary care team.

Without the GP at the core, making assessments, recommendations, and referrals, there’s a real danger that care could fragment for those patients who see a variety of health care providers.

Fragmentation of care is dangerous for the patient and costly for the health system.

It can lead to misses or double-ups – and either of these has the potential to do real harm.

The GP is the only member of the team trained to properly provide continuity of care to the patient – not just during a specific episode of health care – but throughout a patient’s life.

To avoid fragmented care there must be somebody at the core – that somebody needs to be the patient’s GP.

Standing at the helm, facilitating delivery of quality patient care, the GP helps the patient navigate their way through episodes of illness, or through managing chronic disease, as well as supervising and coordinating their long-term health care management.

Patients look to GPs to explain and interpret what may appear to them to be a jumble of services.

GPs act as the coordinator and interpreter of care, the guide for the patient over time and across services.

The GP is the patient’s advocate – helping them and their family to take an active role in the clinical decision-making process and working on their behalf with government and private authorities to maximise access to the services they need.

General practitioners have a commitment to quality care and practice according to the principles of evidence-based medicine.

We work to very high standards. More than 85 per cent of general practices are accredited – a clear and tangible demonstration of their strong commitment to providing safe, quality care to patients.

When government and the media talk about primary health care reform, they often accuse GPs of protecting their patch.

But in the UK, research around their polyclinics – similar to the Australian government’s proposed Super Clinics – has found that patients want to have their own GP to care for them and help guide them though the maze that is a modern health care system.

Patient needs must be paramount in the minds of policy makers when proposing primary health care reform.

What evidence there is demonstrates that effective health systems depend on strong integrated primary health care.

Reforms that do not support the important role of general practice will progressively erode the health system’s function - patients will experience more fragmented and uncoordinated health care - and primary health system costs will inexorably rise.

Any primary health care reform should include government support for general practices to further utilise their practice nurses.

But there needs to be flexibility so that GPs can determine the most appropriate way to utilise the specific skills and expertise of their practice nurses.

Practice nurses already assist GPs with immunisations, wound management, chronic disease management, and in pap smears and associated preventative checks.

The AMA believes that general practice nurses could further assist GPs in the effective management of obesity, blood pressure, and diabetes, as well as in the management of complex and chronic disease and, using GP developed protocols, with screening.

A first step would be to expand the GP practice nurse incentive to all practices.

The second would be to reform the practice nurse items in the Medicare Benefit Schedule so that the GP has some flexibility in effectively engaging the practice nurse.

For example, specific purpose items could be replaced with items that reflect the number of tasks the nurse undertakes on behalf of the GP.

To tie together the work of the primary health care team and to facilitate improved communication strategies between all levels of the health system there must be continued and enhanced support for technology infrastructure.

GPs visiting aged care facilities or operating in remote areas need to have access to their patients’ records and be able to update them on the spot.

GPs need to know when their patients are discharged from hospital and what patient follow-up will be required.

Without a doubt, the best way to keep patients healthy and contain future health spending is to prevent illness.

Preventive medicine includes the prevention of illness, the early detection of specific disease, and the promotion and maintenance of health.

This can include population health initiatives such as immunisation and screening programs, and helping patients quit smoking and address risk factors like overweight.

Primary care services can be optimised to improve delivery of preventative health care in Australia.

Any reforms of the primary health care system must actively promote preventative medicine and support GPs and the GP-led primary care team in this work.

The Medicare Benefits Schedule needs to provide more for preventative health – not through specific items but by supporting a consultation structure that allows GPs to discuss with patients their risk factors and advise them of preventative measures they could employ to maintain or improve their “wellness”.

Studies show that patients who have access to longer consultations with their GPs use other areas of the health system less often - saving the health system and the community money.

While I’m on the subject of the MBS, any reform must include a review of how the MBS is indexed.

The current indexation system undermines Medicare by eroding year after year the value of the patient’s rebate.

The MBS must be indexed to keep pace with any increase in the cost of providing general practice services.

The Government is looking to simplify the MBS – as part of that they must support a final round of grandfathering for eligible non-vocationally registered GPs.

It is confusing and unequitable for patient rebates to significantly vary depending on the vocational registration status of their GP.

The rebate for a GP management plan, for example, is the same regardless of status – but a consultation is not.

Dealing with red tape reduces by up to 25 per cent the available time a GP has to treat patients.

Areas that need to be particularly targeted include Practice Incentive Programs, service incentives, chronic disease items, and authority prescriptions.

Successive governments have ignored repeated recommendations to cut red tape in general practice – this Government must not.

The Primary Health Care Reform Strategy presents the perfect opportunity to take action, reduce this burden and further increase patient access to their GPs.

Treating the whole patient is what GPs are trained to do – to put all the pieces of the puzzle together, treat and manage the patient’s condition and, where proper, direct the patient to the most appropriate health providers.

Primary health care reforms must ensure that GPs remain central to the patient’s journey through the health system.

For that journey to be safe, GPs must not be substituted. They can be assisted, by all means, but not substituted.

We are ready to work with the government to iron out some of the problems I’ve outlined today.

Government and the medical profession must work together to ensure a sustainable health system that will enhance patients’ ability to access quality holistic care in to the future.

Like doctors, governments must protect the patient’s well being first and foremost.

They must have this at the forefront of their mind and acknowledge this as the basis on which doctors and other health groups communicate with them.

If governments are conscious of the patient and their needs they will be more likely to get it right.

And in terms of knowing the patient and their medical needs no one is better placed than the GP.

Government must draw on the knowledge, expertise and experience of those at the primary care front line.

We know the consequences of past failures to understand priorities, objectives and outcomes.

As we address today’s issues and plan for the future we must ensure first and foremost that reforms to primary health care follow the medical profession’s oath to “do no harm”.

We must apply that oath not only to each and every patient, but also to the system as a whole.

[1] Australian Institute of Health and Welfare, Australia’s health 2008, p xiv

[2] AMA Opportunities and Impediments to Flexibility: Report on consultations with key stakeholders on flexibility in medical training and work practices, March 2003 and Wikipedia information about Generation Y - http://en.wikipedia.org/wiki/Generation_Y

[4] Cresswell, A, Australian, 7 August 2008, Doctors turning away ’chronic’ patients as shortage hits cities.

[5] Australian Institute of Health and Welfare, Australia’s health 2008, pp 443-444

[6] Australian Institute of Health and Welfare, Australia’s health 2008, p 359

Dr Rod Pearce, Chair of AMACGP at the Australian Health Congress, Sydney