Australian general practice: time for renewed purpose

Medicine in Australia seems to lurch from crisis to crisis. General practice workforce issues, Medicare and medical indemnity currently occupy centre stage,1 but as long as the need for reform remains high on the healthcare agenda, other crises are sure to follow. Current catalysts for change include the ongoing increase in health expenditure, the impending impact of chronic illness and ageing on healthcare, the need to address the community's demands for access to new drugs and technology, and medicine's abiding focus on cure rather than prevention.

An important ingredient in this cauldron of crises is general practice. Healthcare systems in which primary care has a central role have higher patient satisfaction, lower overall health expenditure, better population health indicators, and lower per capita rates of drugs prescribed. In short, general practice, with its key elements of first contact, comprehensiveness, continuity and coordination of patient care, is central to the health of any healthcare system.2

However, all is not well with general practice. Australian GPs, along with their international colleagues, protest that they are undervalued, overworked and no longer in control.3 "They feel like hamsters on a treadmill. They must run faster just to stay still . . . The result of the wheel going faster is not only a reduction in quality of care, but also a reduction in professional satisfaction and an increase in burnout amongst doctors."4 Assemble any group of Australian GPs and talk will soon turn to how recent Federal Government policies regulating general practice have reduced their fiscal autonomy, increased red tape, eroded their professional time, and diminished the quality of their clinical care.5 This discontent and frustration is responsible, in part, for the current free fall of the Medicare bulk-billing rate.6

However, a more ominous threat to the future of general practice is its increasing unattractiveness as a vocation. Junior doctors in Australia7 and North America8,9 are increasingly dissatisfied with general practice, and are voting with their feet.

Anecdotal reasons advanced for this discontent include the low remuneration and lack of prestige of general practice, the demands of practice that may preclude a life beyond medicine, and the advent of competing players in the delivery of primary care, such as nurse or alternative medicine practitioners.8-10

One determinant of a specialty's standing in the medical community is its performance in research. Australian general practice has some catching up to do in this area.11 Indeed, general practice research appears to be in the throes of an identity crisis. In March this year an international conference of WONCA (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or the World Organization of Family Doctors, for short) was convened in Kingston, Canada, to draft a statement on the importance and future prospects of primary care research.12 It is surprising that such a conference was needed at all. But as noted in the Lancet, ". . . discussion at the conference also revealed the loss of direction — and confidence — that primary care research is presently experiencing. Very few examples of good family practice research were presented . . . The emphasis on reflection at the expense of action was telling — and disappointing."12

With all this doom and gloom, what to do? Our special issue on general practice attempts to address this question.

Kamien (page 10) explores the collective wisdom of Australia's inaugural professors of "community medicine".13 Their achievements have been prodigious, but implicit in their reminiscences and counsel is the hope that deans of medical schools might support general practice more fully, and pursue more vigorously teaching environments beyond those found in esoteric tertiary-care and quarternary-care institutions.13 That this can happen with leadership and vision is illustrated by the continuing advances of general practice academia in the United Kingdom, wherein a third of all UK general practices are involved in community-based undergraduate education.14

Del Mar and his international colleagues (page 26) argue that part of the solution to the woes of general practice is to strengthen its "intellectual aspects" by encouraging "critical thinking" and the pursuit of clinically relevant research.7

The commentators on the contrived bleak scenario of general practice in 2020 — The destiny of general practice: blind faith or 20/20 vision — featured in this issue (page 47) argue that the antidotes to the 2020 poisoning of professionalism include structural reforms and independence of clinical agendas. Kidd (page 16) further stresses that involvement of the Federal Government in general practice vocational training needs to be long-sighted, flexible, and not merely an opportunity for implementing political solutions to current problems.15 If the guardians of this multitiered vocational training program were to get it wrong, they would risk fatally wounding general practice.

General practice in the 21st century will only prosper if its collective focus is on adapting and enhancing its unique characteristics — first contact, comprehensiveness, continuity and coordination of care — so that these are in tune with patient and community expectations and the needs of the community's changing health challenges.

General practice needs to change so that despondency, stress, loss of control and the perceived professional unattractiveness are things of the past. New GPs will need to embrace rather than suffer preventive medicine, exploit the power implicit in patient self-management, have responsive and flexible schedules of single or group visits, and be closely involved as members of interdisciplinary teams in care delivery within the community. They must also use the rich resources of information technology to reduce rather than increase work loads. Finally, general practice needs to accommodate the life-style aspirations of future doctors. Such developments can only restore the individual morale and professional pride of GPs.

Donald Berwick (President and Chief Executive Officer, Institute for Health Care Improvement, Boston, USA) recently observed that "We are carrying the nineteenth-century clinical office into the twenty-first-century world. It's time to retire it."16 To effect such seismic changes in how general practice is provided and remunerated will, no doubt, produce upheaval, but the key to the management of any crisis is control — control of professional purpose, places of practice and pride.

It is time for general practice to move into the 21st century.