Facing the challenges: general practice in 2020

Although the workload has increased since 1996 (as evidenced by the number of GPs per head of population), GP incomes have declined, especially relative to specialist incomes.18 Patient co-payments, although still low by international standards, have begun to increase and to affect access to general practice care by disadvantaged groups, especially in remote areas.19

There is an under-valuing of the generalist skills required to assess a broad range of health problems and manage them in a patient-centred way.20 The erosion of support for the generalist role is due, at least in part, to a failure of education, as well as the seemingly inexorable drive to greater specialisation within health care. This has accelerated the drift towards specialties and semi-specialised areas of general practice, despite the evidence of increased costs and decreased coordination.21

The workforce crisis has affected both availability and the duration of consultations required to deliver quality care.22,23 Although multidisciplinary care is essential to the comprehensive prevention and management of chronic conditions, incentives for practices to employ nurses and refer to allied health services have not fully overcome the financial and organisational barriers facing practices. State governments have increasingly focused the efforts of community and allied health services on post-hospital care, reducing the opportunities for teamwork with general practice in the care of patients who have not yet been hospitalised.

The role of general practice in providing continuity across episodes of specialist, semi-specialist or hospital care is not always accepted. The complexity of care has placed a great strain on communication between general practice and other services, much of which was poorly functioning to begin with. This is especially apparent in the frequent breakdown in continuity and coordination between GPs and hospital-based services.24

Over the past decade, following the GP Strategy Review,25 the Australian Government has made a series of modifications to general practice Medicare items, including support for practice nursing in areas of workforce need. Reimbursements for aspects of quality of care, especially for patients with chronic disease, have also been introduced incrementally. However, this process may be close to its limit, as each new incentive adds to the overall complexity and “red tape”. Although it has had its critics, the new UK Contract for GPs services has provided both a boost to GP incomes and a more integrated approach to funding quality performance, with practices scored across targets for 10 chronic diseases, five organisational areas, measures of the patient experience (including access), and special service provision.26

Exposure to general practice in the prevocational years is about to be introduced and may contribute to greater awareness of the generalist role. However, more explicit education on the unique role and skills required in generalist primary medical care is needed, together with strategies to build the intellectual basis for general practice through investment in general practice research.27 There is a place for more GP involvement in specialist and semi-specialist activities. However, instead of having specialist standards and priorities imposed on general practice, we need a better understanding of how generalists and specialists can complement each other in teams.28

In a number of other countries, general practice has become a purchaser or commissioner of services.29 This allows general practice to take a more direct role in negotiating the provision of allied health or secondary services, thus strengthening the position of general practice. This is not feasible in Australia in the absence of patient registration and effective integration between Commonwealth- and state government-funded health services. However, some Divisions of General Practice have become involved in providing or brokering public and private allied health services in the prevention and management of chronic disease, and this appears to be successful in terms of improving both access and coordination.30,31

Although there is increasing recognition in government of the need for greater integration between general practice and other health services, it has been unclear who should take the lead in coordinating care, for example in the management of complex problems in early childhood or in older people. GPs themselves have been ambivalent, feeling that greater integration may threaten their autonomy.

One approach has been to set up structures for greater collaboration between public and private services and between Commonwealth- and state-funded services, such as the Primary Care Partnership models in Victoria.32 These have met with some success, especially in planning service development, bringing population and individual health care approaches together and facilitating multidisciplinary care. The collaborative nature of this approach means that there is less threat to the autonomy of the individual professions and services. However, the capacity of this approach to deal with issues of access or efficiency is correspondingly limited.

Another approach is to bring together general practice with other primary health providers in the one service. Aboriginal Community Controlled Health Services and Integrated Care or Community Health Centres, which bring together GPs, private and state-funded allied health and community health services, exemplify this approach. These facilitate multidisciplinary care and accountability for providing access to comprehensive care. They also provide a basis for greater integration between general practice and other primary health services.