General practice: unity in diversity

Most of the world is yet to have access to any effective form of primary care. This is a tragedy created by lack of practitioners and infrastructure, prohibitive fees, and indifference to the plight of the poor. About 300 000 mothers, many of them teenagers, die each year in childbirth for lack of simple primary care in the least economically developed nations (http://www.who.int/mediacentre/factsheets/fs348). But there are encouraging signs. In the 6 years I have been visiting India as part of a review team invited by the Ministry of Health, I have seen maternal mortality reduced by women in remote villages — trained for a couple of days and equipped with no more than a mobile phone and a bicycle — who help pregnant women gain access to safe environments providing postpartum treatment and basic support for mother and child (http://www.nrhm.gov.in/monitoring/international-advisory-panel/minutes-of-the-international-advisory-panel.html). There are now 800 000 of these women working in India. Simple changes that take account of local needs and conditions can have a huge effect.

Australia has about 25 000 general practitioners (http://www.phcris.org.au/fastfacts/fact.php?id=6775) and I marvel at their commitment and creativity as they have adapted to working together in new ways through Divisions of General Practice and now in the more comprehensive Medicare Locals. They are reformatting the way we provide primary care and adapting to the challenge of long-term support for people with serious and continuing illnesses. But there is more to be done. In this issue (doi: 10.5694/mja13.10298), former Royal Australian College of General Practitioners president Claire Jackson reviews progress in response to the National Primary Health Care Strategy. Despite improvements in integrating primary care with other services, achievements in e-health, an increase in general practice registrar positions, and improved coordination of people with complex needs, we still have some way to go with workforce, access to services, integration with the secondary and aged care sectors, and fiscal efficiency.

The diverse roles of general practitioners, as they care for people in individually negotiated ways, are also featured in this issue. Catling-Paull and colleagues bring some data to the much-contested topic of publicly funded homebirth (doi: 10.5694/mja12.11665). Ward and colleagues (doi: 10.5694/mja12.10820) describe the impact of incentives for general practitioners and parents on rates of vaccination, while Kaczmarek and colleagues (doi: 10.5694/mja13.10044) investigate reasons for increased notifications of pertussis in recent years. Zurzolo and colleagues’ finding that many parents of children with food allergies have trouble interpreting food warning labels will not surprise many general practitioners (doi: 10.5694/mja12.11669). Zurynski and Elliott (doi: 10.5694/mja13.10424) highlight the problem of transitional care for older children with rare diseases, and suggest a role for specialist general practice clinics. For clinical fodder, the first article in our new Cardiology series (doi: 10.5694/mja12.11054) revisits the importance of absolute cardiovascular disease risk in primary prevention.

The challenges facing general practice include the sheer diversity of clinical responsibility, making sense of new bureaucratic fantasies and upheavals, adapting to reporting schedules for new services that remind us of the adage “pulling up seedlings to see if the roots are growing”, and distribution of an ageing workforce. Matters of money, lagging fee schedules, and work conditions, such as long hours and lack of locum relief, can cause great stress.

Yet general practitioners remain at their posts. Why? I venture it is because they experience great and appropriate satisfaction from the connections they make with the people who come to them for care, as reflected in Links and Bikou’s tale of coming to understand a patient at the end of life (doi: 10.5694/mja13.10290). Nothing else makes sense as an explanation.

In this issue, we offer articles drawn from a range of disciplines relevant to general practice. This diversity underscores general practice’s central place in the health system of what is, after all, a country blessed with a sophisticated, highly skilled and increasingly integrated health care workforce.