View - Canadian Family Physician

editorialsPrimary care reformView from AustraliaGrant Russell, MBBS, FRACGP, MFM Geoffrey Mitchell, MBBS, FRACGPAustralia and Canada have much in common:remote locations, harsh landscapes, urbanconsolidation, and sparse rural populations. Bothnations view family practice as being fundamentalto good primary health care. Although both havebeen embarking on policies of primary care reform,the reform processes have had substantially differentphilosophies, structures, and outcomes.Canadians are proud of their health system.Yet in recent years, the system’s universality,comprehensiveness, and accessibility have beenshaken by the effects of increasing medicaltechnology, contraction of the hospital sector,an aging population, and widespread physicianshortages. All have contributed to a situationwhere access to care is becoming difficult, healthservices fragmented, and health care workersincreasingly demoralized. 1In response, there has been no shortage ofproposals for reform, particularly in the area of primarycare. Government, 2 medical organizations, 3,4and health advocacy groups 4,5 have tackled theissue. Most, if not all, have focused on restructuringthe organization and reimbursement of familypractitioners. 1 Many reform models specify patientrostering and large investments in informationtechnology. With general support from the profession,pilot projects have begun in many provincesto test another common theme: primary carenetworks (PCNs). These “real or virtual” familypractitioner groups are designed to deliver 24-hourprimary care to enrolled patients. 6Despite two decades of endeavour, no provincehas implemented meaningful reform. 1 In the sameperiod, Australia has revolutionized the organizationand delivery of general practice care. 7 At thistime of uncertainty in Canadian family medicine,perhaps something can be learned from theAustralian experience.Australian health systemSince 1974, Australians have had access to universal,taxpayer-funded basic health insurance.This compulsory federal scheme (now calledMedicare) underwrites physician fees and providesfree public hospital care. Two fifths of thepopulation purchase additional health insuranceto cover in-patient care in one of the nation’s manyprivate hospitals.Australian general practitioners (GPs) aregatekeepers for specialist care and deliver mostprimary clinical services. Although permitted toset their own fees, 40% of GPs choose to directlyinvoice the government for all clinical services, aprocess known as “bulk billing.” 7 The governmentreturns a predetermined rebate (commensuratewith the bulk-billed fee) to patients who have beenissued private accounts.Despite the central role of Australian GPs, thelate 1980s saw deep concerns being expressedabout their professional role. Isolated from otherparts of the health care system, GPs had minimalinput into health decision making, a poor academicbase, and inconsistent training. 8 Medicare’s feestructure encouraged rapid consultations and providedminimal incentives for preventive activities,home visits, or after-hours care. 9 The rural GP workforce was decreasing, and many practitioners werewithdrawing from hospital and obstetric care. 8Australian GP strategyMajor changes followed a 1991 consensus agreementbetween the Federal Government, theRoyal Australian College of General Practitioners(RACGP), and the Australian Medical Association.The resulting “General Practice Strategy” wasdesigned to improve the integration, quality, andcomprehensiveness of GP care. General practitionerswere given an opportunity to have astake in the design and implementation of healthpolicy. The strategy included specific initiativesto improve rural and indigenous health and tostrengthen the research capacity of primary care.Other reforms have occurred in parallel (Table 1).The most visible sign of reform has beenformation of 123 “Divisions of General Practice.”440 Canadian Family Physician • Le Médecin de famille canadien VOL 48: MARCH • MARS 2002

editorialsThese geographically based organizations representnetworks of approximately 150 GPs (rangefrom 12 to 800). The Federal Government providesinfrastructure funding to enable divisions toengage in cooperative activities to address healthneeds at the local level. 10 Divisions are managedby boards elected by local GPs. Standards ofreporting were set relatively low at the outset buthave steadily increased with time and are nowlinked with national health priorities and demonstrablehealth outcomes. 8The GP strategy is underpinned by a philosophyof quality improvement for both practitioners andpractice. Private general practices are eligible forTable 1. Australian general practice initiatives, 1989-2000OUTCOMEOBJECTIVE STRATEGY LOCAL SYSTEMICIntegrate Divisions of Generalgeneral practice Practicewith healthsystemOrganized links between GPs andlocal hospitals and communityhealth servicesGP-based strategies developed tomeet national health goals andtargetsLocal public health initiativesusing existing GP networksChange in system from hospitalpre-eminence to a better balancewith community servicesPrimary health carereformsPatient-based funding of GPs forparticipation in case-based activitiesinvolving other health care providersNational primary health careresource webpageImprove qualityof clinicalpracticeVocational registrationCommitment to continuing medicaleducation and practice auditImproved quality of primarymedical servicesSetting qualifications for entry intounsupervised practicePractice incentivepaymentsCommitment to after-hours serviceprovision• Targeted incentives, eg,immunization rates• Embracing informationtechnology• Rewarding commitmentto rural practice• Recognizing medicaleducation commitmentsVoluntary practiceaccreditationProfession-based accreditation process,unrelated to official funds at presentRedistributework forceRural incentives programRetraining and relocating urban GPs torural practiceLong-term strategies to attract theright number of appropriatelyskilled physicians to rural areasRural education programMedical schools funded to provide ruralimmersionRural student clubs fundedStudent scholarships for repeatedimmersion in one districtImproveacademic baseGeneral PracticeEvaluation ProgramIncreased GP presence and influence inmedical schoolsIncreased research outputDevelopment of critical mass ofGP academicsEvidence base for strategicdecisions relating to general practiceImproved academic standing of generalpractice within universityGP input into national strategicdecision makingImproved professional self-esteemPotential for improved evaluation ofcommunity- based programsVOL 48: MARCH • MARS 2002 Canadian Family Physician • Le Médecin de famille canadien 441

editorialsblended payments designed to complement traditionalfee-for-service income. These “practice incentivepayments” reward comprehensive after-hourscare, rural practice, teaching medical students,and practice computerization. More recently, theFederal Government has initiated a scheme thatpays GPs to provide comprehensive health assessmentsto elderly and aboriginal patients, participatein interdisciplinary case conferences, and developmultidisciplinary patient management plans. 11As in Canada, GPs need approved postgraduatetraining before registering for independentpractice. Continued registration requires proofof participation in continuing medical education(CME), much of which is delivered by divisions.Rural GPs have become eligible for salary subsidiesand locum tenens relief, and many are fundedto participate in CME. Substantial incentives havebecome available for urban GPs to retrain beforethey relocate to rural areas.The academic base of the discipline has beenstrengthened in several ways. Government fundingof peer-reviewed research and evaluationprojects has helped define and articulate the disciplineof Australian general practice. 12 Universitydepartments have been funded to develop Mastersprograms in family practice and public health, andnumerous doctorate and Masters scholarshipshave been awarded to junior GP academics.OutcomesThe GP strategy has had a substantial effect. Afteryears of exclusion, GPs have been invited back intometropolitan teaching hospitals. Funded hospitalliaison positions for GPs have improved communicationbetween the hospital and the community.Hospitals have joined GPs in many shared-careinitiatives in areas ranging from after-hours accessto medical care to care for mentally ill patients. Theinitiatives have improved continuity of care andconvenience and have reduced patient anxiety andpostdischarge complications. General practitionershave benefited from a greater sense of involvement,while hospitals have identified improved efficiencyand increased capacity. 13The strategy has heralded a substantialincrease in use of information technology (IT)in general practice. Individual practices receivedconsiderable one-time payments in 1998 forbecoming computerized. Most divisions facilitateIT consultancy and bulk purchasing services. 10Among practices receiving incentive payments,76% use computerized prescribing, and 86% cantransfer health data electronically. 14 CoordinatedGP-based strategies have helped lift nationalimmunization rates to 92%. 15The effect of the Australian GP strategy hasbeen facilitated by circumstance. Unlike Canada,the Federal Government is free to design andimplement health policy. Australia’s medical workforce is plentiful and is not tempted to migrate to alarge affluent neighbour. However, several federalpolicy decisions have also worked against the aimsof the original GP strategy. In particular, governmentlimitations on postgraduate training placeshave exacerbated real GP shortages in less populatedregional and urban areas. The internationallyrespected RACGP postgraduate training programhas been dismantled. In its place local consortia willplace tenders for educational services from externaltraining providers. Although more than 85% ofGPs have joined divisions, 16 considerable resentmenthas been expressed that the strategy was“funded” through savings resulting from freezingGP Medicare rebates in the early 1990s. Despitequality-linked payments, steady increases in practiceand medical indemnity costs and decreasinguse of procedures 7 have led to concerns aboutpractice viability. 17 As in other Western countries, 18dissatisfaction and psychological disability havebeen increasingly recognized among GPs. 19 Whilethe pace of change is a likely contributor, manydivisions have implemented strategies to improvepractitioners’ health and well-being. 20LessonsThe most striking difference between the AustralianGP strategy and the published proposals forCanadian primary care reform (apart from degree ofprogress) is that Australia has nurtured rather thanimposed change at the practice level. By contrast,nearly all of the Canadian proposals require familydoctors to radically change the style, structure, andfinancial basis of their practices. Recent proposalsstrongly advocate that each PCN be staffed by physicians,nurse practitioners, and a range of allied healthworkers. Many have advocated local fund-holdingand the phasing out of fee-for-service payments forfamily physicians. Patients will be formally enrolledin these fundamentally different practice structures.While we admire the Canadian propensity to subsumeindividual needs for the greater good, we wonderwhether the pedestrian pace of change indicateshow the community and their family doctors havetaken to such proposals.Australia’s conservatism at the practice levelcontrasts with a much more radical approach tohealth service integration. The divisions have442 Canadian Family Physician • Le Médecin de famille canadien VOL 48: MARCH • MARS 2002

editorialsprovided common ground for different parts ofthe health care system to cooperate, interact, andplan for the future. This is facilitated at all levels:from local populations (where four fifths of divisionshave formal community liaison structures),to hospitals, allied health organizations, and stateand federal governments.These initiatives have strengthened the role ofgeneral practice within the wider health system.Primary medical care has become more communitybased, has a preventive focus, and yet retainsthe continuity, comprehensiveness, and patientorientation of traditional general practice.Although integration is acknowledged in manyCanadian primary care reform proposals, 3 itsevolution seems to depend on serendipity ratherthan structure, commitment, and funding. Itseems more than likely that “real or virtual” PCNswould be far too preoccupied with the managerialchallenges of these new workplaces to be able tocooperate effectively with the community or widerhealth system. These roles might default to theCollege of Family Physicians of Canada, provincialmedical associations, or university departmentsof family medicine. Despite the best of intentions,these bodies have neither the capacity, the perspective,nor the mandate to fulfil such tasks.Integration does not come with a computer network.It does not come when family doctors are“provided” with nurse practitioners. It comes whenseparate organizations can work together on problemsthat they are unable to address effectively ontheir own. 21 It requires planning, nurturing, andtime. The Canadian proposals to radically alter traditionalfamily practice without true health systemintegration are likely to sell family practice short.Indeed, any opportunity for wider systemic reformhas been substantially delayed or has even disappearedwhile the finer details of practice-basedreform are endlessly argued.Australia has discovered that a broad, pragmaticstrategy can reward and reinvigorate generalpractice. Canada’s preoccupation with radical,practice-based reform risks dismantling a servicethat has been a defining aspect of the Canadianhealth system. It would be sad to see our familypractitioner colleagues linked by computer, coveringcall 24 hours a day, but watching impotently asthe rest of the health system passes them by.AcknowledgmentWe have received payments from individual Divisions ofGeneral Practice for work on divisional boards and on anumber of divisional evaluation projects. We have alsoworked at various times for the Royal Australian College ofGeneral Practitioners.Dr Russell is a Saw Research Fellow at the Universityof Western Australia. He was a Visiting Professor in theDepartment of Family Medicine at the University of WesternOntario from 2000 to 2002. Dr Mitchell is Senior Lecturer inthe Department of General Practice and Community Health atthe University of Queensland.Correspondence to: Dr Grant Russell, Centre for Studies inFamily Medicine, 245-100 Collip Circle, London, ON N6G4X8 or to the Department of General Practice, Universityof Western Australia, 328 Stirling Highway, Claremont WA6010, AustraliaReferences1. Rosser W, Kasperski J. Organizing primary care for an integrated system.Healthcare Papers 1999;1(1):5-21.2. Barer ML, Stoddart GL. Toward integrated medical resource policies forCanada. Report prepared for the Federal/Provincial/Territorial Conferenceof Deputy Ministers of Health. Ottawa, Ont: Health Canada; 1991.3. College of Family Physicians of Canada. Primary care and family medicinein Canada. A prescription for renewal [position paper]. Mississauga, Ont:College of Family Physicians of Canada; 2000. p. 1-32.4. College of Family Physicians of Canada. Profile of family practice in Ontario.In press 2001.5. Rachlis M, Evans RG, Lewis P, Barer ML. Revitalizing Medicare: shared problems,public solutions. Toronto, Ont: The Tommy Douglas Research Institute;2001. Available at: www.tommydouglas.ca. Accessed 2002 Feb 1.6. Government of Ontario. Harris launches the Ontario Family Health Network[press release]. Toronto, Ont: Government of Ontario; March 21, 2001.7. The General Practice Strategy Review Group. General practice. Changing thefuture through partnerships. Canberra, Australia: Commonwealth of Australia,Department of Health and Family Services; 1998.8. General Practice Branch, Commonwealth Department of Health andFamily Services. General practice in Australia: 1996. Canberra, Australia:Commonwealth of Australia; 1996.9. National Health Strategy. The future of general practice. (Issue paper No. 3).Canberra, Aust: Australian Government Publishing Service; 1992.10. Magarey A, Rogers W, Veale B, Weller D, Sibthorpe B. Dynamic divisions.A report of the 1997-98 Annual Survey of Divisions. Canberra, Australia:Commonwealth Department of Health and Aged Care; National InformationService; 1999.11. Commonwealth Department of Health and Aged Care and the NationalInformation Service. Primary care initiatives: enhanced primary care package.Adelaide, Aust: Flinders University of South Australia; updated 2000 Nov 10.Available from: http://www.health.gov.au/hsdd/primcare/enhancpr/enhancpr.htm.Accessed 2001 Aug 13.12. National Information Service of The General Practice Evaluation Program.Decade of GPEP projects. 1990-1999. Adelaide, Aust: National InformationService. Department of General Practice, Flinders Medical Centre; 2000.13. Lloyd J, Powell-Davies P, Harris MF. Integration between GPs and hospitals:lessons from a division-hospital programme. Aust Health Rev 2000;23:434-41.14. Health Insurance Commission. Practice incentives program: participationstatistics. Canberra, Aust: Commmonwealth of Australia. updated 2001 Nov23. Available from: http://ww.hic.gov.au/CA2568D90003F3Af/page/PIP-Statisticsparticipation?OpenDocument&1=45-PIP~&2=53-Statistics~&3=15-participation~.Accessed 2001 Aug 13.15. Health Insurance Commission. Australian childhood immunisation register:coverage. Canberra, Aust: Commmonwealth of Australia; updated 2002 Jan 18.Available from: http://www1.hic.gov.au/general/acircirgtb04.Accessed 2001 Aug 13.16. Australian Divisions of General Practice. Annual report 1999-2000.Canberra, Aust: Australian Divisions of General Practice; 2000. p. 30.17. The Royal Australian College of General Practitioners. Wirthlin WorldwideAustralasia (Sydney). State of general practice. South Melbourne, Aust: RoyalAustralian College of General Practitioners; 2001; updated 2001 Sept 4. Availablefrom http://www.racgp.org.au/document.asp?id=1814. Accessed 2001 Aug 3.18. Appleton K, House A, Dowell A. A survey of job satisfaction, sources ofstress and psychological symptoms among general practitioners in Leeds. BrJ Gen Pract 1998;48(428):1059-63.19. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med JAust 1998;169(3):133-7.20. Primary Health Care Research and Information Service. Activities of divisionsdatabase. Adelaide, Aust: Primary Health Care Research and InformationService; updated 2002 Jan 14. Available from: http://som.flinders.edu.au/FUSA/GPNIS/Nisdb/Contents/DIVLIST.HTM#state. Accessed 2002 Jan 31.21. Gray B. Conditions facilitating inter-organisational collaboration. HumRelations 1985;38(10):911-36.VOL 48: MARCH • MARS 2002 Canadian Family Physician • Le Médecin de famille canadien 443