General practice: professional preparation for a pandemic

General practice, with its 33 700 general practitioners,1 is the backbone of the Australian primary health care system; Australians consult GPs 94 million times per year.2 Seasonal influenza is managed mainly in the community, with most care provided by GPs and pharmacists.

General practice will have to deal with the impact of a pandemic on its workload and workforce. In Australia, up to 7.5 million excess consultations might be required during a pandemic.3 Furthermore, health workers are likely to acquire influenza, and an estimated 9% of GP work days could be lost at the peak of the pandemic.4 Some general practices may close, as seen during the recent outbreak of the severe acute respiratory syndrome (SARS), where 7.4% of Hong Kong5 and 37.5% of Canadian6 general practices closed. Therefore, the substantial increase in demand during a pandemic is likely to occur in the setting of a health care infrastructure struggling with staffing, resource, transport, and social crises.

The experience with SARS in Ontario led to the development of the Canadian pandemic influenza plan.7 This advocates an inclusive planning process from national to municipal governments, with emphasis on communication, ethical decision making, local antiviral stockpiling, and enhancing the capability of the hospital system to cope with increased numbers of admissions (the surge capacity). In Australia, state/territory and Commonwealth governments have developed multi-stakeholder plans3,8-10 based on internationally recognised strategies.11 Most plans acknowledge the potential role of the GP in such a disaster,3,8-10 but there are few published data discussing the pivotal issues that GPs and their practices will face in dealing with such a crisis, or documenting the strategies which might be needed at a practice level.12

GPs are acknowledged as the masters of uncertainty13 in their clinical work. However, uncertainty coupled with disagreement tends towards complexity, and then chaos.14 In a situation that will be new for most Australian GPs, how can we minimise uncertainty and disagreement to ensure the best organised response to this crisis?

Local research suggests Australian GPs are likely to continue to work, influenced primarily by their sense of responsibility for their patients’ welfare, but also by their responsibilities to their GP colleagues.12 However, GPs have caveats to this position. These include the provision of adequate protection (personal protective equipment [PPE] and antiviral medications) for themselves and their close personal contacts (including family members and practice staff).

GPs have also identified conflicting clinical roles that will challenge them ethically and logistically during a pandemic. These include reassuring the “worried well”, dealing with influenza patients, managing patients with conditions unrelated to influenza, and dealing with the mental health issues (especially fear, anxiety and bereavement) during and after a pandemic. There are also significant non-clinical dilemmas to be faced by GPs and their staff. What remuneration should be paid to staff who decide not to work? How will the practice function if key clinical or non-clinical staff are absent? What billing procedures should a practice adopt? GPs need to consider their personal position and that of their family and staff, as well as their professional responsibilities, in deciding on their approach to these issues.

A further area of uncertainty for GPs will be medical indemnity. What provision might be made for practitioners providing telephone and email advice to quarantined patients? What of practitioners drafted to run fever clinics? How quickly could recently retired members be re-indemnified for practice? These issues are best addressed before a pandemic, and the medical defence organisations need to advise their members of their intentions.

A suggested pragmatic checklist to assist GPs and their practices with pandemic planning is given in Box 1 and Box 2. Many strategies should be introduced now. However, the structures of general practices are very diverse, and include single practitioners with limited staff and practice space. A major challenge will be to assist individual practices to assess their own circumstances and make the best decisions around pandemic planning for their particular situation, linked with municipal and state/territory plans.

Government has a responsibility to oversee pandemic planning and can authorise any legislative powers required during such an outbreak. Professional bodies must be invited to advise on these processes. The Royal Australian College of General Practitioners (RACGP) is already involved in government planning for a pandemic. The RACGP has a pandemic preparedness group and can identify issues relating to quality, education and standards and communicate strategies to GPs. The Australian Medical Association is focusing on industrial issues that may arise before, during or after a pandemic. Both these organisations, along with the Australian Divisions of General Practice, are represented on the National Influenza Pandemic Action Committee’s Primary Care Working Group, which is soon to publish a Primary Care Annex to the Australian health management plan for pandemic influenza.3

Workforce surveillance will be critical in a pandemic. Emergency operations and logistics personnel require timely information regarding the status of general practices — whether they are open or closed, seeing patients with pandemic influenza or not, and how GPs will provide services to patients (clinics, telephone assessment and management, or home visits). Divisions of General Practice are well positioned to carry out workforce surveillance, as they have the best established local networks of all GP support organisations. Additionally, at a local level, Divisions play a crucial role in providing educational, administrative and some clinical support to general practice. They are ideally placed to link general practice with all aspects of government pandemic planning. Divisional surveys of current and retired members’ intentions during a pandemic may be crucial to health authorities’ decision making. Emergency operations personnel need to track workforce capacity during a pandemic; Divisions can advise whether there is the potential for redeployment of primary health staff to other duties, such as fever clinics, or act to absorb hospital staff into primary care settings. They can provide academic detailing to practices in advance of a pandemic, and assist with infection control, vaccination and PPE supply. Divisions may also be able to coordinate appropriate reimbursement for participation in pandemic preparedness.

The link between all points in the pandemic planning chain is vital to ensure the best outcome. Rapid, clear and two-way communication at an interpersonal, telephone and electronic level will be instrumental in supporting the various national, state and local plans. One key difference in planning for a future pandemic is the wider variety of media available for transmitting information than was available in past epidemics. Health websites, public health broadcasts, television channels, radio segments and newspaper articles are all currently used by medical professionals to convey health messages. They must be harnessed for the benefit of the wider population before, during and after a pandemic. The power of the doctor in such a “consultation” should not be overlooked.

Provision of resources to enable the actions demanded by various pandemic plans is the third key area for general practice preparation. In primary health care, the human resources (both clinical and non-clinical) will be the front-line. Training, protection, remuneration and indemnity are important areas of concern for all groups. Locally based organisations are the logical choice to provide support. However, currently the Divisions receive little funding to support pandemic preparedness, and if their contribution is to be maximised, Divisions need to receive adequate funding for this.

Some areas of Australia are well supplied with GPs, but workforce shortages are recognised in some rural and outer metropolitan regions. A redistribution of clinical support to bolster local numbers will be required, and is likely to be one of the contentious issues of pandemic planning.

Whether the resource is a human one, a protective one, or a monetary one, there is an absolute requirement for government support. As Winston Churchill once said, “It is no use saying, ‘We are doing our best.’ You have got to succeed in doing what is necessary.”

GPs are old hands at dealing with uncertainty in clinical practice. However, when this uncertainty is coupled with anxiety, lack of clear information and limited awareness about strategies to manage the range of possible scenarios, the outcome is more likely to be chaotic. The more certain we become of our abilities to act in a pandemic situation and the closer to agreement we are on how the best outcomes can be achieved, the more likely we are to engage in rational decision making, and play a clear and key role in maintaining and protecting the health of the Australian public.