Recent changes in Australian general practice

Introduction

"Coordinated care", "managed care" or "integrated care" (all are basically synonymous) have been introduced in other countries to ensure cost and service efficiencies or to maximise profit in the delivery of health care. Health planners in the United States have some difficulty understanding what we are seeking to achieve in Australia with coordinated care, as Australia is perceived as having a potentially very effective care coordinator called a general practitioner, a care coordinator which the United States is seeking to emulate! Given recent experiences (e.g., making private health insurance a more attractive product, or seeking acceptable ways to encourage quality care in general practice) in attempting to work in partnership with governments, it is not surprising that many in our profession, and GPs in particular, have major reservations about this latest proposal.  

Recent developments in Australian general practice

Recognition of general practice

In August 1991, the then Federal Health Minister, Mr Brian Howe, announced a number of "reforms" in general practice, which included fundholding (or budget holding) (see Box 1).

• Address supply and distribution of medical practitioners;
• Introduce accreditation of general practices;
• Provide practice grants to complement fee-for-service reimbursement;
• Trial the use of practice budgets;
• Amalgamate solo and small-group practices into larger, more efficient entities; and
• Optimise use of information technology in general practice.

Both the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP) declared that general practice fundholding was unacceptable, not only because of the perceived threat to traditional fee-for-service practice, but also because of the absence of linkage of patients to practices and the lack of effective information management in Australian general practices. Recent information on the experiences of GPs in the United Kingdom, ³ New Zealand (Professor Greg Coster, Chairperson, Royal New Zealand College of General Practitioners, personal communication) and Canada (Dr Reg Perkin, Executive Director, The College of Family Physicians of Canada, personal communication), where fundholding in various forms had been introduced, would appear to support this position.

In response to the "reforms" proposed in 1991 and after extensive negotiations between the AMA, the RACGP and the Federal Government, a joint report entitled "The future of general practice: a strategy for the nineties and beyond" ⁴ was released in July 1992 (Box 2).

• Address the oversupply and maldistribution of general practitioners;
• Provide support and recognition for appropriate postgraduate training for general practice;
• Establish local "divisions of general practice" under the control of general practitioners;
• Develop (by the profession) an independent, voluntary system of practice accreditation with links to regional divisions of general practice; and
• Introduce remuneration strategies designed to:
  -- reward quality care in general practice more appropriately; and
  -- enhance and encourage the role of general practitioners beyond the provision of individual patient care.

This report was distributed widely to all GPs and to other interested parties, and working groups were formed to develop strategies to implement a number of these proposals.  

What has occurred
as a result of this report and what is the future for GPs and general practice?

• How many practising and non-practising GPs are there in Australia?
• How many identified general practices are there?
• How many additional GPs are required for rural and remote areas?
• What are the essential skills required for GPs to practise confidently and safely in the various areas of need?
• How many GPs are needed in Australia altogether?
• Is there a limit to the number of GPs Australia can support and afford?
• How many GPs are enough?

The Federal Government has imposed an annual limit of 200 overseas-trained graduates entering the Australian medical workforce (almost all of whom seek to become GPs). ⁵ Entry to the RACGP Training Program has been restricted to 400 per year, ⁶ and the argument used by the government for limiting the number of GPs entering the workforce has been the reportedly unsustainable rate of growth in payments for GP services.

There are allegedly too many GPs in most metropolitan areas and a very evident lack of GPs in many rural and remote areas throughout Australia. Despite various incentives, most Australian GPs appear reluctant to spend time in rural general practice. Many GPs have reported that, even in the cities, there is a shortage of both doctors willing to work as locums as well as skilled GPs available to fill vacancies resulting from practice growth or GP resignation or retirement.

Recognition of appropriate training for general practice
Vocational registration and restricting entry to general practice continue to be a source of anger and resentment. Medical students, recently graduated hospital doctors and those unsuccessful in specialist training had, in the past, an expectation of a right to enter general practice, together with those doctors who considered general practice as a retirement option or a retreat when their original career ceased to be satisfying or rewarding. Such doctors often still refuse to recognise that general practice requires any particular training.

The terms "vocational registration" and "recognised GP" will remain a mystery to most consumers until we, as a profession, accept what much of the developed world, and the World Health Organization in particular, has already accepted: that general practice is a specific discipline in medicine and not merely the sum of special areas of knowledge from other more restricted disciplines. Only then can we unite to promote the excellence of general practice in Australia. It is ironic that Australia is regarded internationally as having one of the highest standards of general practice in the world, but yet is one of the last developed countries to afford real recognition to the discipline.

Formation of divisions of general practice
Contrary to popular opinion, the concept of divisions of general practice was not a government initiative but arose from within the profession. Divisions were conceived to provide GPs with a strong voice at a local level in their interaction with other local and regional bodies. Members of other Australian medical disciplines have been able to aggregate and organise in hospital "divisions" or departments. This permitted specialists to provide effective hospital clinical services, to undertake teaching and research collaboratively and to provide a professional interface with other disciplines and hospital administration while still retaining their independence.

The RACGP had been keen to address the isolation and problems of fragmentation and marginalisation of Australian general practice. There was agree ment for a means to enable local GPs to work together more closely while still retaining t heir independence. In particular, at a local level GPs needed to not only plan their own futures as GPs but also have an input into the important area of health care planning for their communities. These concepts led to divisions of general practice and their proposed roles (Box 3).

• Maintain and improve the standards of general practice in the region, including coordination of care between general practitioners and other service providers for the benefit of patients;
• Improve communication between general practice, hospitals, medical specialists and community health services;
• Encourage involvement of GPs in hospitals and other community health services;
• Foster cooperation between GPs in providing quality after-hours services;
• Take an active role in the continuum of education from undergraduate through to postgraduate vocational training in general practice;
• Undertake research in general practice by establishing local research networks;
• Involve GPs in health promotion and preventive activities;
• Ensure appropriate access to primary health services in consultation with consumers by sharing allied health resources; and
• Assist in the development of appropriate information management in general practice.

During 1992, 10 groups of GPs from various parts of Australia obtained Federal Government funding to develop local GP organisations, later called divisions of general practice. By the end of 1995 there were 116 divisions of general practice covering 85% of the Australian community.

The divisions, and projects promoted through divisions, have been subject to increasingly rigorous evaluation. Inevitably, some are proving more successful than others. The first ten divisions, formed in 1992, appear to be flourishing. Some more recently formed divisions may need a longer time to demonstrate their potential, and some of the early projects proposed by the divisions were poorly developed and sometimes only partially successful. To ensure that divisions of general practice have a future they will need to demonstrate that they are having a positive effect on community-based health outcomes and that this effect is sustainable.

Development of practice accreditation
The concept of the accreditation of general practices (i.e., the environment in which GPs work) has proved to be highly controversial. Perceived benefits are outlined in Box 4. To provide a basis for such accreditation required the development of agreed standards.

• Raise general practice standards and consequently the quality of care provided to patients;
• Provide professional benefits for general practitioners; and
• Facilitate change in general practice.

During 1993-1994 the RACGP Standards Development Unit developed "Draft entry standards for general practice", ⁷ with input from a wide variety of individuals and organisations. In 1994 these draft entry standards were tested in 199 practices through the RACGP Field Test of Standards. A further 500 practices, coordinated through divisions of general practice, undertook local demonstration trials to enable further evaluation of the standards and methods of assessment.

While there has not been universal acceptance of the concept of accreditation, responses from participating GPs in both the RACGP field tests and the local demonstration trials strongly suggested that the standards were acceptable and appropriate, that the process was found to be professionally satisfying, and that a better understanding of the standards acted as a catalyst for change in the practices surveyed.

One reason for Federal Government support of the concept of accreditation was that it might provide a basis for allocation of funding not dependent on number of patient consultations (i.e., rewarding quality care rather than throughput). The debate around accreditation should not revolve around money but around standards:

• How are the standards established?
• Are they are accepted by GPs as well as the rest of the profession?
• How they are applied?
• Do they have external credibility to consumers and others outside the profession?

Remuneration strategies for general practice
There was initial agreement that the existing fee-for-service funding for general practice had an inbuilt "perverse incentive" based on "the more you see and the quicker you see them the more you earn". The RACGP, the AMA and the government were not able to reach agreement on a method of remuneration that encouraged and rewarded the provision of high quality care, other than on a time basis. Agreement attempts were not aided by the Government's part-funding of the general practice reforms, including the introduction of the so-called Better Practice Program, from the funding pool for the fee-for-service rebate increases. That action was totally contrary to the agreed position stated in the general practice strategy document that "Funding for these payments would come from a pool of funds set aside by the Government but the establishment of this pool should not interfere with rebates for fee for service items for vocationally registered general practitioners", ⁴ and has resulted in the return of an atmosphere of mistrust of government by the profession.  

GPs being part of change

References

1. Department of Human Services and Health. Council of Australian Governments Taskforce on Health and Community Services. Meeting peoples' needs better -- a discussion paper. Canberra: The Department, January 1995.
2. Health Care in Australia -- directions for reform in the 1991-92 Budget. (Circulated by The Hon Brian Howe, Deputy Prime Minister and Minister for Health, Housing and Community Services.) Canberra: AGPS, 1992. (Budget related paper, No. 9.)
3. Miller G, Booth N. General practice budget holding. What can the United Kingdom teach Australia? Med J Aust 1995; 162: 284-285.
4. Department of Human Services and Health/Australian Medical Association/Royal Australian College of General Practitioners. General Practice Consultative Committee. The future of general practice: a strategy for the nineties and beyond. Canberra: Department of Human Services and Health, July 1992.
5. Commonwealth Government Budget 1995-96. Fact Sheets -- Medical Workforce. Canberra: AGPS, 1995.
6. Royal Australian College of General Practitioners. Program of Vocational Training -- Conditions of Grant Schedule 3. Specific outcomes for 1994-95. Canberra: Department of Human Services and Health, 1994.
7. Royal Australian College of General Practitioners. Standards Development Unit. Draft entry standards for general practice. Sydney: The College, 1994.