A model of team care with a GP at the hub could bring Australian general practice out of its crisis and help it thrive, as it does in the Netherlands.
Although the recent budget announcements for general practice are welcome, more is needed to reduce reliance on hospital services in the community and respond to increasing disruption by commercial parties.
The concept of the “GP consultant” should be explored and encouraged, in combination with adding more members to the general practice team. Funding provided by the Commonwealth to states and territories through the National Health Reform Agreement should be used to better connect primary care with the hospital system.
“I can’t get in to see the GP” is a phrase often heard these days, coming from patients presenting to state health services including emergency departments. According to the AIHW, in 2021-22, 25% of people delayed seeing a GP for reasons such as service availability or waiting time.
Some forecasts suggest that urban and rural areas in Australia will become progressively and significantly undersupplied with GP services between now and 2030. The AMA predicts that Australia may be short more than 10,000 full-time GPs within a decade.
Other parties moving into primary care
Hospitals are also overwhelmed. In some states the growth in demand for public hospital services continues to exceed population growth. State health services are desperately looking for solutions and have gradually been expanding their services to provide acute care and chronic disease management in the community, in an attempt to fill the gaps in primary care.
Initiatives such as Choosing Wisely, Evolve, Right Place Right Time and Healthdirect aim to direct patients and clinicians towards appropriate care options, away from more expensive hospital care and towards community services.
Driven by activity-based funding, hospitals are offering care via community outreach teams, mobile services, hospital-in-the-home, hospital ED clinicians in residential aged care facilities, virtual ED, virtual clinics, and virtual hospitals. The aim is to treat more patients in the community – which is a worthy goal – but this often happens with limited or no primary care involvement and ambiguity about clinical governance and end-responsibility.
Funding incentives are not aligned. For example, patients admitted through hospital-in-the-home or virtual services are unable to claim a Medicare rebate for telehealth consultations with their GP, even though they are residing in their own homes. As a result, virtual teams may be assuming responsibility for whole-of-person care, including chronic disease management and mental health, for patients admitted for an acute problem.
Commercial parties are now stepping in primary care, with for example online providers, Bunnings, Woolies, Amazon and others taking a significant share of the non-Medicare primary health care market.
Other industries, such as the pharmacy sector, are changing rapidly, partly due to the impact of artificial intelligence, which is replacing manual medication preparation and dispensing, enabling pharmacists to focus their attention on patient-centred tasks. The North Queensland community pharmacy scope of practice pilot and similar initiatives elsewhere in the country are signs of the changing landscape.
Effects of disruption and underfunding
As state health services move into communities, growth in hospital expenditure continues to outpace primary healthcare expenditure. General practice is the most accessed part of the healthcare system, but government expenditure per person on general practice has been almost seven times less than hospital care.
Patients are being asked to fund the gap. The overall bulk-billing rate for non-referred GP attendances has dropped below 80% and is at its lowest point in 15 years. Decades of underfunding of general practice in combination with stalled or failed reform attempts appear to have taken their toll, affecting workload, job satisfaction and patient access to general practice.
The “crisis” terminology has been used regularly in recent times, and not just in Australia. For the moment, general practice appears to have lost its appeal and young doctors are avoiding general practice.
The GP model of care has not changed significantly over the past decades and is in desperate need of repair. While the recent budget announcements will provide a welcome boost to general practice, more is needed to strengthen general practice teams. Some argue that it is not just about more dollars and more doctors, but also about changing the way GPs work together with other primary care providers.
The RACGP Vision for general practice and a sustainable healthcare system explains the benefits of high-performing general practice and makes recommendations to restructure the healthcare system. The Strengthening Medicare Taskforce Report summarises many of the challenges and opportunities with regards to blended funding systems, data and digital reform, voluntary patient registration and multidisciplinary team-based care, to sustain primary care into the future.
A stronger primary care sector can provide the care currently delivered by hospital community programs and other providers. This would have benefits for patients from a continuity of care perspective and would be cost effective. However, GPs cannot deliver this care on their own and will require additional support and appropriate incentives.
Better utilising multidisciplinary care
In many cases, multidisciplinary teams are essential for optimal care and may ease pressure on the GP workload. It is an important underpinning argument of voluntary patient registration in Australia. For example, a team approach will be required to keep people living with complex chronic conditions out of hospital. Yet, there are different opinions within the profession about what team care looks like and what the role of the GP in these teams should be.
It appears that to date, insufficient work has been done to develop mechanisms that integrate the work of GPs, practice nurses, allied health providers and pharmacists through adequate funding models, information sharing and team care arrangements. Linking primary care teams with hospital programs, for example to support frequent hospital users, is generally not facilitated through current funding programs.
Current Medicare billing rules often prevent multidisciplinary care, such as nurse-led activities within general practice. General practice nurses are underutilised due to Medicare and medicolegal insurance hurdles. At the same time, nurse-led vaccination clinics were made possible during the height of the covid-19 pandemic.
In the Netherlands GP teams are supported by assistants who perform medical procedures such as taking blood pressures, urine dipsticks, suture removal, ear syringing, vaccinations as well as non-clinical medical reception duties. Dutch practice nurses focus on chronic disease management and mental health care.
Dutch GPs appear to spend less time on activities at the bottom of the scope, such as issuing sick certificates (these are dealt with by occupational medics). GP training in the Netherlands is in high demand and steadily growing, with one-third of medical graduates choosing a career in general practice.
The GP consultant model
Supported by adequate funding models, non-GP members of Australian general practice teams could work more efficiently within their full scope of practice, under the delegated authority of a “GP consultant” who would be available on site but would not have to see each patient for billing purposes.
Although most GPs recognise the benefits of increasing the level of team care, one study demonstrated they were struggling to come to terms with the implications of this for their individual working practices. Assuming the role of GP consultants within a team requires, to a certain extent, letting go of the historical one-on-one model of general practice, which may be easier for some than for others. In some cases, it may also require developing supervision and coordinating skills.
The case mix of the GP consultant would move towards the top of their scope of practice, which makes sense from an efficiency point of view. Although the higher complexity of the case mix may be challenging for some, working in a multidisciplinary team as a consultant will increase the sense of support and satisfaction, and administrative and non-clinical tasks are shared with team members.
The number of patients seen by GPs will likely shrink and efficiency gains will occur through coordinated team care. Practices that have implemented this model report positive experiences. This model is an argument to bring remuneration of GP consultants in line with hospital consultants.
Strengthening the GP team
A significant number of patients reviewed in hospital outpatient clinics could be managed more appropriately in primary care. This would improve hospital access for patients who are waiting for an outpatient appointment but are still managed in primary care. In general, increasing capacity in general practice is a key requirement to improve hospital discharges when clinically appropriate.
Current hospital outreach and mobile services are staffed by multidisciplinary teams including nurses, nurse practitioners, allied health and hospital specialists. To provide a similar level of service, GPs will need support from additional members in their team.
Roles that could help strengthen the team are the physician assistant and the pharmacist in general practice, while GPs with a Special Interest could function as an additional port of call for peer support and advice in the community.
Physician assistants are clinicians working as a member of a multidisciplinary team under the delegation and supervision of a GP. The individual physician assistant’s scope of practice is determined by the supervising GP and defined in an agreed practice plan. This model has been successfully implemented in emergency departments.
Depending on the available special interests and skills in general practice teams, physician assistants could play a role in for example general practice urgent care, palliative care, and telehealth services, responding to a service demand that is at present filled by hospitals and commercial providers.
As part of the GP team, physician assistants would be a link between patients and their regular GP or other members in the multidisciplinary team, facilitating continuity of care. Physician assistants can support GPs with post-discharge management to keep people well in the community, reducing the risk of re-presentations to hospital.
Continuity of care would be provided by whole-of-practice teams, not just GPs. The specifics of how GPs and other members of the team would work together need to be clarified and mutually agreed to avoid unintended consequences.
New funding models
Activity-based hospital funding is a strong driver for state hospitals but is not an incentive to empower partners to provide similar care. States are concerned that innovative funding models create conflicting incentives, leading to reduced funding for ongoing hospital activity. The challenge is to collaborate, not replace primary care with other (often more expensive) services.
The National Health Reform Agreement (NHRA) is the agreement between the Australian Government and state and territory governments. It is traditionally a hospital funding agreement, directing activity-based hospital funding. The Commonwealth contributes 45% and state and territories 55%. The NHRA could be used to provide better coordinated and joined up care in the community to ensure the future sustainability of Australia’s health system.
For example, part of the funding provided to the states and territories through the NHRA could flow to models of multidisciplinary care across primary-secondary care. Some have suggested to increase the Commonwealth NHRA share from 45% to 50% and invest the additional 5% in shared care models that reduce hospital demand and improve patient outcomes in the community. Australia spends very little on prevention compared to other OECD countries. There is an opportunity for the National Health Reform Agreement to focus more on preventive health.
New NHRA primary care funding mechanisms would complement traditional Medicare fee-for-service, voluntary patient registration, workforce incentive programs and other blended funding arrangements, to assist with strengthening multidisciplinary care.
A better mechanism to govern the interface between primary care and secondary care should be developed through formalised partnerships between hospitals and Primary Health Networks, supported by agreed health pathways and general practice liaison officers to facilitate communication and shared care.
The value-proposition of some PHNs could be optimised by joint planning and commissioning with hospitals, in consultation with general practice representatives.
Connected care initiatives need to be supported by secure electronic messaging systems and data sharing between hospitals and primary care. An example of effective data sharing is the NSW Lumos project. Similar initiatives that can identify individual patients at risk of frequent hospital use, would assist in better targeting chronic disease management efforts by GP teams. Similarly, data sharing between general practices could improve patient safety and reduce duplication.
Learning from the past
Given the modest success of health reform efforts in Australia, we need to learn from mistakes made in the past. New models must be carefully co-designed, piloted, reviewed and re-designed, based on learnings (and not abandoned after a failed attempt). Stop-start funding and project funding with no budget for permanent funding should be avoided.
Health consumers should have a voice in the design of services to ensure they are fit-for-purpose and sufficiently interconnected to support patients on their journeys across the boundaries of our healthcare systems.
Flexibility in the modelling is required to respond to local area needs and available skills and capacity. Increasing the connections and collaboration with other disciplines and parts of the healthcare system is a must and can no longer be ignored.
Edwin Kruys is a GP in the hinterland of the Sunshine Coast, member of the RACGP Expert Committee Funding and Health System Reform and co-chair of the Queensland General Practice Liaison network. This article is based on his personal opinions and does not reflect the position of the RACGP or Queensland Health.
