Issues And Challenges For General Practice And Primary Health Care
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Final Report September 2009 1 General Practice and Sustainable Primary Health Care — the way forward Final Report—September 2009
ACT GP Taskforce
Final Report September 2009 2 Table of Contents
Letter from Co-Chairs………………………………………………………………………..5 Taskforce Membership……………………………………………………………………....6 Executive Summary…………………………………………………………………………..7 Summary of Recommendations………………………………………………………….10 Chapter 1 – Talking General Practice……………………………………………………14 Introduction………………………………………………………………………….14 Consultation Process………………………………………………………………14 Chapter 2 – Workforce Challenges……………………………………………………....16 Introduction………………………………………………………………………….16 -Workforce Supply……………………………………………………………...17 -Better Support for General Practice…………………………………………....18 Short-term Sustainability………………………………………………………...... 20 -Overseas recruitment……………………………………………………….....20 Short to Medium Term Sustainability…………………………………………....21 -The Part-time Workforce…………………………………………………….....21 -Re-entry to the Workforce……………………………………………………..22 Longer Term Sustainability………………………………………………………..22 -Non-medical GP Workforce…………………………………………………...23 Summary ……………………….…………………………………………………..25 Chapter 3 –Sustaining General Practice………………….……………………………...26 Introduction………………….………………………………………………………26 Evolving Service Models…….…………………………………………………….27 Health Literacy and E-Health.…………………………………………………….28 Red-tape………………….…………………………………………………………29 ACT Snap Shot………….………………………………………………………….30 -General Practice Sizes…………………………………………………………30 -Access and Bulk-Billing………………………………………………………...31 -General Practice Nurse Workforce………………………………………….....31 Conclusion …………………….……………………………………………………31 Chapter 4 –Strong Links and Liaison……………………………………………………..33 Introduction…………………….……………………………………………………33 Vulnerable Populations……….……………………………………………………33 Aged Care …………………….…………………………………………………….34 Transport…………………….………………………………………………………36 Conclusion………………….……………………………………………………….36
Final Report September 2009 3 Chapter 5 –Records: Access and Legislation………………………………………....37 Introduction………………….………………………………………………………37 Access and Legislation…….………………………………………………………37 Conclusion ………………….………………………………………………………39
References………………….………………………………………………………………..40 Appendix 1 –List of Submissions………………………………………………………..41
Final Report September 2009 4 Letter from Co-Chairs to ACT Minister for Health
Ms Katy Gallagher Minister for Health ACT Legislative Assembly London Circuit CANBERRA ACT 2601
Dear Minister,
We are pleased to present this report, which is the result of wide discussion with the ACT Community, the health sector and general practice.
This report presents the outcome of the ACT GP Taskforce’s debate and deliberation following consultation with a broad range of people and organisations. The Taskforce was pleased to receive submissions and input from health professionals, health and consumer interest groups, general practice and the general community. The Taskforce members acknowledge the contributions of these people and their commitment to the challenge of building sustainable primary health care services, especially general practice services, for Canberra.
The report builds on the GP Taskforce discussion paper of June 2009, which presented a comprehensive picture of general practice across the ACT and was designed to encourage debate and input relevant to the terms of reference of the ACT GP Taskforce.
Whilst it is acknowledged that the long term vision of creating sustainable general practice services will take time, and require collaboration across a range of stakeholders, it is also clear that there are a number of short-term actions that can be taken to help set the direction.
On behalf of the Taskforce members, we would like to thank you for the opportunity to consider this critically important issue and commend this report to you.
Yours sincerely,
Ross O’Donoughue and Dr Clare Willington Co-Chairs ACT GP Taskforce
Final Report September 2009 5 September 2009
GP Taskforce
Co-Chairs
Mr Ross O’Donoughue, Executive Director, Policy Division, ACT Health
Dr Clare Willington, ACT GP Advisor, ACT Health
Members
Dr Rashmi Sharma, President, ACT Division of General Practice
Dr Paul Jones, President, AMA ACT
Professor Nicholas Glasgow, Dean, ANU Medical School
Professor Marjan Kljakovic, Director, Academic Unit of General Practice and Community
Health
Ms Veronica Croome, ACT Chief Nurse
Ms Ann Wentworth AM, health care consumer representative
* We note the valued membership of Ms Janne Graham AM, health care consumer representative, during the development of the Issues and Challenges for General Practice and Primary Health Care Discussion Paper.
Final Report September 2009 6 Executive Summary
The way forward
The Final Report of the ACT GP Taskforce provides the ACT Government with a range of recommendations that may, if implemented, support the provision of general practice and build a system of sustainable primary health care for Canberra. Building upon the GP Taskforce Discussion Paper June 2009 (see http://www.health.act.gov.au/c/health? a=da&did=10010771&pid=1245368728) the Final Report consolidates findings from extensive consultation, debate and deliberation around the accessibility and the sustainability of ACT general practice and the primary health care sector, now and into the future. The Taskforce acknowledges the important contribution that stakeholders have made in forming this report and its recommendations.
The ACT Health Minister established the ACT GP Taskforce in March 2009, with the following terms of reference: review and consolidate work already undertaken by the ACT and Commonwealth governments on access to primary care services in the ACT. explore and recommend on legislative options to protect the rights of patients and the health workforce. advise on workforce demand and training issues in primary health care, with regard to currently available published information. explore and recommend on options and innovations to improve access to primary health care services in the ACT, including opportunities that may arise in the Commonwealth – State and Territory health reform agenda. consider and make recommendations on provisions to improve access to primary care services for vulnerable populations, including the aged, people with mental illness and the isolated.
To fulfil the Terms of Reference, the ACT GP Taskforce undertook wide public consultation. Twenty-three public submissions were received in response to the GP Taskforce Discussion Paper June 2009. Formal consultations were held via three public forums (in Civic, Belconnen and Tuggeranong), an aged care sector forum hosted by the ACT Division of General Practice (ACTDGP) and a primary health care sector forum jointly hosted by the GP Taskforce and the ACTDGP. In addition, a number of interviews and meetings with key stakeholders were also conducted and Taskforce members attended as invited guests, forums hosted by the ACT Health Care Consumers Association and the Tuggeranong Community Council.
Final Report September 2009 7 Over the past five months the ACT GP Taskforce has considered the available information and listened to the views of health professionals and the community. It became evident during this period that there was little current and reliable information about general practice size and their locations. In partnership with the ACT Planning and Land Authority (ACTPLA), the Taskforce was able to map information from a snap shot telephone survey of general practices. This mapping exercise provided extremely useful information.
It is clear that general practice is a system under pressure and is experiencing many changes in distribution and workforce. The Taskforce is of the view that the GP shortage will worsen before workforce supply improves. Urgent action is needed and solutions will not be instant. To ensure sustainability, these actions must focus on short-term strategies whilst the building blocks for medium and longer term strategies are being laid. The next decade will present many challenges and opportunities for general practice.
The Taskforce members agree that the predominant challenge for delivering primary health care in Canberra is the general practice (GP) workforce shortage. The reasons for the undersupply of full time equivalent GP workforce are complex and the impact is broad. The GP workforce shortage is resulting in changes to practice locations and composition. Closure and merger of general practices is driven by older GPs retiring and reducing their working hours. While the community values the traditional model of a small (less than four GPs) practice at the local shops, over the next few years there will likely be a redistribution of GPs into larger practices grouped closer to town centres in the ACT.
When practices close or merge, the storage and availability of patients’ records is a significant issue that is governed by the Health Records (Privacy and Access) Act 1997. The Taskforce has concluded that the provisions under the Act in relation to notice of practice closure and arrangements for access to health records are not well understood —either by the community in general or the medical profession. Current uncertainty has resulted in inconsistent information about access to records and general practice locations in Canberra and confusion and inconvenience to the community. To address this confusion, the Taskforce is of the view that legislation should be amended to improve access to health records and clarify the requirements for notification of opening and closure of general practices.
The workforce shortage within general practice is impacting upon access to primary health care for vulnerable populations. The Taskforce considers that the most urgent area for action in the provision of primary health care is aged care. The provision of care to older residents of Canberra, especially those who are frail and house bound, and to those living in residential aged care facilities needs urgent attention.
Final Report September 2009 8 New models of care, based upon the foundations of existing skills in the GP sector and upon the existing MBS provisions, offer a way to overcome the challenges associated with the GP workforce shortage and the impact that this is having on vulnerable populations. A sustainable primary health care service for people living in residential aged care facilities will require new thinking. The aim must be to create an effective primary health care system that avoids unnecessary emergency department presentations.
Canberra is well placed to explore new models of care and become a centre for innovative ways of providing primary health care. Interprofessional primary health care teams offer an opportunity for general practice to partner with nursing and allied health professionals to provide comprehensive team based health care. While many GPs may continue to operate in a traditional model of practice the Taskforce is aware that emerging opportunities for new models of care may be welcomed by some GPs and provide a reason for Canberra to be attractive to GPs wanting to practice in new ways in an urban setting. Developing new models will require robust links between services in the primary health care sector. This will assist specific populations of Canberrans who currently experience considerable difficulty accessing general practice.
The ACT Government has embarked upon an ambitious program of service planning for Canberra’s future. The Capital Asset Development Plan will provide significant new infrastructure and could support accommodation and e-health for a hub and spoke model of care to link people with complex needs to practices through a collaborative service provided between ACT Health and Canberra general practices. General practices and other primary health care services could be engaged to form a “virtual” comprehensive primary health care service, consistent with proposals in the recent report of the National Health and Hospital Reform Commission.
The ACT Government E-health Future Package is the potential platform for establishing a network of all the components within the health care team while also assisting health care consumers to take a more active role in their care. E-health could support team work, integrate services and support evaluation and monitoring of the health care system. It could also contribute through point-of-care testing, electronic decision support, home monitoring and improved communications. The Taskforce concludes that systems need to be developed that allow for safe, seamless, and efficient electronic linkage and transfer of information between patients, carers and members of their treating team to maximise service integration. Furthermore, the Taskforce is of the view that general practice should be the central point or “health care home” for collection and coordination of information for health care consumers care in an e-health environment.
While the ACT works towards a sustainable future primary health care system, the current GP workforce shortage must be addressed. The ACT urgently requires more GPs. To achieve this will require making general practice an attractive choice for young
Final Report September 2009 9 doctors. Junior doctors are not choosing to train in general practice because it is considered to be under-funded, professionally highly demanding, and of a lower status compared with other medical specialties. GPs are being paid increasingly less than their specialist colleagues. The Taskforce concludes that addressing remuneration issues would go a long way to towards addressing the workforce supply.
Recruitment of doctors from outside the ACT is not easy. A number of obstacles, some of which relate to the Australian Government Department of Health and Ageing rural and remote region and District of Workforce Shortage requirements require further thought. The GP ratio to population must be a fundamental consideration in whether the Australian Government supports an area of workforce shortage and the provisions for outer metropolitan areas and District of Workforce Shortage arrangements need to apply to the whole of Canberra. Local incentives, at least in the short term, are also necessary for Canberra to compete in a very tight labour market to attract international and Australian medical graduates to work in ACT.
The Taskforce agrees that medium term strategies should focus on two groups of GPs in need of particular supports in order to sustain their participation in clinical practice; GPs re-entering the workforce after parental leave and older GPs wishing to cut back their hours and who no longer wish to run a general practice. There is clearly a need for a re- entry program to support GPs back into the workplace and for opportunities for GPs to work in areas of special interest such as aged care.
Medium term strategies must also build on the other members of the health care team. Allied health disciplines are fundamental to effective and evidence based primary health care services, while nursing is taking on an increasingly important role in the provision of general practice. General practice nursing is a growth area and recent research by C. B. Phillips and her team has shown that nurses in general practice are centrally important in the provision of clinical care and the overall sustainability of general practices [Phillips, C. B., Pearce, C. M., Dwan, K. M., Hall, S., Porritt, J., Yates, R., Kljakovic, M., Sibbald, B., July 2009, Charting New Roles for Australian General Practice Nurses http://www.anu.edu.au/aphcri/ Spokes_ Research_Program/Stream_Three/Phillips_abridged_25.pdf]. The Taskforce believes that promoting and supporting the role of nursing in general practice is important and that the ACT is well positioned to promote further research into nursing in general practice.
In the longer term, primary health care service sustainability will require developing a whole of career strategy for general practice. The Taskforce agrees that the ANU Medical School, the Academic Unit of General Practice and Community Health, together with the local training group of Coast-City-Country Ltd and ACT Health already provide the platform for excellent teaching and learning in general practice. This platform needs to be built on to make Canberra and region the most highly regarded setting for aspiring GPs to study medicine in Australia.
Final Report September 2009 10 In conclusion, the ACT GP Taskforce makes 30 recommendations that provide a way forward for general practice and sustainable primary health care.
Summary of Recommendations
Workforce Challenges Workforce supply: 1. In order to inform policy, planning and mapping, ACT Health to annually review the ACT GP workforce by conducting a telephone snapshot survey and considering other available workforce data.
Better Support for General Practice: 2. Improve the uptake of doctors into general practice by implementing the following ACT Government 2009—10 GP Workforce Budget initiatives: o Teaching Incentive Payment to support GPs teaching undergraduate medical students o PGPPP that enables newly trained doctors to gain clinical experience in general practice o Scholarships providing incentives to choose training in general practice 3. Continue to work with the Australian Government and Coast-City-Country Training Ltd to establish more local GP training positions. 4. Support the ANU Medical School GP Student Network (GPSN) and other student activities related to general practice. 5. Continue to support existing general practices through the provision of grants to encourage infrastructure and sustainable workforce.
Final Report September 2009 11 Short Term Sustainability: Overseas recruitment 6. Work with the Australian Government to extend the District of Workforce Shortage provisions to the whole of the ACT, for at least the next four years or until the number of GPs in the ACT reaches the average per 100,000 of population for similar metropolitan regions and include those working toward Royal Australian College of General Practice Fellowship to have access to provider numbers in the ACT. 7. Explore new and competitive incentives to attract GPs to relocate to the ACT, including the feasibility and efficacy of a low or interest free loaning scheme to encourage the establishment of new GP practices within Canberra. 8. Increase the GP Marketing and Support Officer role to full-time. 9. Focus strongly on Australian and overseas GP recruitment for the next four years.
Short to Medium Term Sustainability The Part-time Workforce 10. Market the ACT to GPs as a place of work choice and flexibility with employment opportunities additional to usual GP clinical work in government, education, research and innovative models of service provision. Create and publicise opportunities for GPs over 55 years of age to remain engaged with work in general practice in the ACT.
Re-entry to the Workforce 11. Support GPs taking parental leave to stay engaged in the clinical workforce by developing a suite of supports including access to childcare and provision of re-entry programs for GPs returning to the clinical work place.
Longer Term Sustainability Non-medical GP Workforce 12. Request the Australian Government to extend the Outer Metropolitan Provisions to the whole of Canberra and thereby support all general practices to employ a practice nurse. 13. Work in partnerships with the education sector and general practice to develop a career pathway for general practice nurses, including nurse practitioners. 14. Work with stakeholders to explore the potential for new support roles such as medical assistants in general practice.
Evolving Service Models
Final Report September 2009 12 15. Develop and evaluate new models of primary health care service delivery which include a generalist medical component of care that would provide comprehensive primary health care to targeted populations otherwise unable to access usual GP services.
Final Report September 2009 13 Health Literacy and E-Health 16. Develop and maintain a service provider directory for Canberra and the surrounding region. 17. Work in partnership with stakeholders to ensure the centrality of general practice in the development of the e-health record.
Red-Tape 18. Strengthen links between the ACT Division of General Practice, the Royal Australian College of General Practitioners the Australian Medical Association ACT, ACT Government, the Australian Government and other agencies to consider ways to address “red-tape”.
Vulnerable populations 19. Support existing general practices to provide comprehensive primary health care to vulnerable populations in partnership with other relevant services. 20. Strengthen governance within ACT Health to support the practice of primary health care and the teaching and learning of general practice. 21. Promote Canberra and the region as leading the field in interprofessional teaching and learning for primary health care professionals with a strong emphasis on interprofessional team work and building communities of practice.
Aged Care 22. Build capacity to provide primary health care services to people in residential aged care facilities by developing a new aged care service that supports existing general practices, as well as allowing GPs who wish to specialise in providing services to older people, to work in a new model of service provision. 23. Roll out the in-hours locum service to support GPs and residents of residential aged care facilities.
Transport 24. Ensure that in the Sustainable Transport Action Plan 2010 – 2016 provisions are made to manage the projected increase in demand for transport to and from health care appointments, including the establishment of bus stops and shelters directly outside any new general practices as part of the Sustainable Transport Action Plan 2010 – 2016. 25. Clarify and publicise the criteria for accessing Government funded community transport services.
Final Report September 2009 14 26. Recommend improved communication between regional community services who provide both HACC and community bus transports.
Records: access and legislation 27. Easy to read guidelines are developed and distributed for the community and the profession explaining rights and obligations in regard to access to health records under the Health Records (Access and Privacy) Act 1997. 28. Current legislation be amended to: Mandate a period of four weeks notice to consumers and the community before closure or mergers of a practice can occur with examples of appropriate ways to notify the community. Allow the general provisions for consumer access to health records be extended to closure and transfer of practice. Remove the three week restriction in Principle 11 to allow records to be transferred immediately when required and include provisions that allow a practice to prioritise the transfer of health records, e.g. releasing records for current patients before past patients. Include an appropriate period of time for a record keeper to transfer a health record to another service provider when requested by a consumer. Clarify the status of e-health records. Provide that the current fees for access to health records be extended to the transfer of health records on closure or merger of a practice. Introduce a mandatory requirement that on closure of a practice health practitioners notify the Health Service Commission (HSC) regarding where the health records are to be stored. Current fees for health records transfer are extended to the transfer of health records on closure of a practice. 29. The roles and responsibilities of the HSC in relation to health records are clarified and publicised to the community and the profession. 30. Introduce a mandatory requirement for the notification of GP practices to a relevant government authority to be activated when a practice opens, closes, merges or transfers.
Final Report September 2009 15 Chapter 1 – Talking General Practice
Introduction In the five months since the ACT GP Taskforce was established, there has been extensive consultation, debate and deliberation around the accessibility and the sustainability of ACT general practice and the primary health care sector, now and into the future. The Taskforce notes the release of the National Health and Hospitals Reform Commissions report, A Healthier Future for All Australians Final Report June 2009. The recommendations from this report, particularly in relation to aged care and primary health care services present significant opportunities for the ACT. Recommendations made in this report could lead to initiatives in health care service delivery that create opportunities for collaboration between ACT Health and Commonwealth funded initiatives. Of interest to the Taskforce are the national recommendations around workforce challenges and initiatives in service provision [see http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report]. The next few years present challenges and opportunities locally as well as nationally. The ACT Government has made a substantial commitment to the development of health service infrastructure which will support changes in the delivery of health care services across the health system.
Consultation Process
The Taskforce developed a Discussion Paper—GP Taskforce Discussion Paper June 2009 which provided a basis for thinking about the issues facing general practice and consolidates the key challenges for the primary health sector; workforce sustainability, changing demand for services, education and training, primary health care networks and access for vulnerable groups. It also presented the views of a number of people working in general practice and consumers on aspects of general practice service provision. The paper discussed the diversity of perspectives in general practice and highlighted the complexities of service delivery and the challenges in balancing community and clinician needs. The paper also discussed some short-term and longer term strategies for consideration.
A six week public consultation phase was undertaken using the Discussion Paper and related questions as a prompt. The Taskforce received 23 submissions, in various formats (see Appendix 1 for a summary list of submissions).
The following formal consultations were also held: Three public forums held in Civic, Belconnen and Tuggeranong
Final Report September 2009 16 An aged care sector forum hosted by the ACT Division of General Practice (ACTDGP) A primary health care sector forum jointly hosted by ACT Health and the ACTDGP
In addition, members have attended as invited guests, forums hosted by the Health Care Consumers Association and the Tuggeranong Community Council. A number of meetings with key stakeholders were also conducted. The Taskforce considered all submissions and listened to the debate generated by the profession and the wider community. The Final Report of the ACT GP Taskforce—General Practice and Sustainable Primary Health Care — the way forward aims to present an overview of the findings of the consultation, debate and deliberation undertaken by members of the Taskforce. The Final Report also provides a number of recommendations including short, medium and long term strategies for the ACT to support sustainable primary health care service provision in the ACT.
It is the view of the ACT GP Taskforce that there is urgent need for action, that our challenges are significant and that the solutions will not be instant. We must boost short-term strategies while the building blocks for medium and longer term strategies are being laid. To ensure sustainable provision of primary health care services and general practice as a critical component, we must act now.
Final Report September 2009 17 Chapter 2 – Workforce Challenges
Introduction The predominant challenge for delivering primary health care in Canberra is the general practice (GP) workforce shortage. This was discussed in detail in the Discussion Paper “Issues and Challenges for General Practice and Primary HealthCare” June 2009. Addressing the GP workforce shortage is going to take time. The reasons for the undersupply of full time equivalent workforce are complex. The Taskforce has noted the research undertaken by Associate Professor Dr Kirsty Douglas and her team at the Australian Primary Health Care Research Institute around the part-time GP workforce [Douglas K, Dwan K and Forrest L, ACT work in progress, Sessional GP Project]. It also acknowledges that whilst the overall number of GPs (head count) in Canberra appears adequate, the participation in clinical general practice translates into the second lowest full-time equivalent in the country [Australian Government, Report on Government Services 2009, http://www.pc.gov.au/gsp/reports/rogs/2009]. The reasons for this discrepancy relate to many factors, that are clearly described in the Taskforce Discussion Paper and a recent paper by Associate Professor Douglas and her colleagues [Douglas, K., Rayner, F., Yen, L., Wells, R., Glasgow, N and Humphreys, J. 2009, The Medical Journal of Australia. Australia’s primary health care workforce — research informing policy, 191 (2): 81-84]. Recent research conducted in the ACT suggests that asking individuals who work part-time in mainstream general practice to work more is not a viable or realistic solution [Douglas K, Dwan K and Forrest L,]. However, GPs are already engaged in all areas of the health care system and part-time general practitioners may be willing to engage in clinical work that operates in new service models as well as mainstream private practice [Douglas K, Dwan K and Forrest L].
A challenge for the Taskforce has been to obtain up to date information about the ACT general practice workforce. The dynamic nature of the general practice workforce means that national workforce publications are outdated before they are published, and there is no central up-to-date public repository of GP workforce information. For this reason, the Taskforce has undertaken some collation of information available in the public domain to assist its deliberations. This was conducted as a snapshot in early July 2009 of basic GP service provision undertaken in a snapshot phone survey. In addition, the Taskforce considered information provided by the ACT Medical Board and the ACT Division of General Practice on the demographics of general practitioners. These findings are presented in the table and graph on the next page.
ACT Medical Board 2009 data shows that 37per cent of the ACT GP workforce is over 55 years of age. Furthermore, female GPs are becoming the majority of the workforce and make up two thirds of the GP workforce under the age of 45. There is considerable evidence that women, particularly those under the age of 45, are more likely to work part-time in clinical general practice. However, the ACT Sessional GP Project conducted
Final Report September 2009 18 by Associate Professor Douglas and her team shows that GPs in Canberra who work part-time in clinical general practice are also often engaged in either personal and family commitments and / or a number of other activities related to health care. These range widely across teaching and research, policy and government advice, clinical operations within ACT Health as well as, participation in the private health sector and non-government organisations [Douglas K, Dwan K and Forrest L]. The significant contribution of Canberra’s GPs to the work of government, academia and the health sector as a whole is noted by the Taskforce.
Final Report September 2009 19 GP Workforce snapshot:
Total GP's = 365 GP Age Distribution 50 Gender Percentages: 45 Female = 49% Male = 51% 40
Female Male 35 s '
Average Age 48 53 P G
30 Age Distribution (1 f o
SD) 9 10 r e 25 25-29 3 3 b m u
30-34 11 4 N 20 35-39 18 11 40-44 31 14 15
45-49 31 32 10 50-54 37 32 55-59 34 46 5
60-64 10 27 0 65-69 3 7 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 70-74 * 7 29 34 39 44 49 54 59 64 69 74 79 84 89 75-79 * * Male Age Grouping 80-84 * * Female 85-89 * * Total 179 186 No. with 2nd Jobs 20 18
(Data from the Medical Board of the ACT)
Many GPs see the ACT as an ideal environment to work across a portfolio of professional activities which complement and balance their clinical work in general practice [Douglas K, Dwan K and Forrest L]. This diversity in activity seems to be characteristic of Canberra and is enabled by the small geographic scale of the ACT and the many institutions and professional opportunities which it contains. A recent survey of Canberra GPs by the ACTDGP supports that this diversity of professional opportunity, which seems to be special to Canberra, contributes to a high degree of professional satisfaction in a significant proportion of Canberra GPs. However, the Taskforce recognises the diversity in the workforce and notes the serious challenges and stressors faced by many GPs especially those responsible for the operation of small and medium sized practices.
Workforce Supply Consultations with GPs suggest that the workforce shortage will not be corrected in the short term. In 2007 the GP shortage is only marginally better than it was in 2004 (Report on Government Services 2009,
Final Report September 2009 20 Table 11.1: Availability of GPs (full time workload equivalent) http://www.pc.gov.au/__data/assets/ pdf_file/0006/85407/46-chapter11- attachment.pdf ). To compound this, the Taskforce received submissions from GPs close to retirement concerned that they will not be able to pass their practices on to younger GPs. There are insufficient full time equivalent GPs entering the workforce to balance retirement and the trend towards part-time work. Closure of general practices when GPs retire or practices merge, results in a loss of intrastructure, additional to a diminished GP workforce. On balance, these factors point to the shortage worsening before the GP workforce supply improves—we face a difficult decade.
Another impact of the GP workforce shortage is that practice locations and composition are changing. At present about half of Canberra’s general practices are ‘small’, defined as less than four GPs (Taskforce Survey June 2009). The trend to practice closures and mergers is increasing as older GPs retire and reduce their working hours. The next few years will see the continued redistribution of GPs into larger practices grouped closer to town centres in the ACT. In ten years time the provision of primary health care is likely to be significantly different as a result of the pressures affecting the GP workforce at different points in the professional lifecycle.
Addressing the workforce shortage requires more GPs. However, the message that came across strongly during consultation was that newly trained doctors do not see general practice as an attractive choice. Advice from the local GP training group, Coast- City-Country Ltd, and from consultations with younger doctors suggests that junior doctors are not choosing to train in general practice because it is under-funded and is regarded as highly professionally demanding and of a lower status compared with other medical specialties.
The salary gap between GP and other specialists in Australia is also widening [OECD Health Data 2009]. GPs are being paid increasingly less than their specialist colleagues. Addressing remuneration issues would go a long way to towards addressing the workforce supply. The Commonwealth Medicare Schedule Review Board conducted a remuneration rate study in 2000 which pointed to the need to remunerate general practice adequately, in relation to other medical specialties and other professional groups [http://www.health.gov.au/internet/main/publishing.nsf/Content/D5805C64E0C2D09ECA 256F180048DBDA/$File/rrsfinalreport.pdf].
Recommendation: 1. In order to inform policy, planning and mapping, ACT Health to annually review the ACT GP workforce by conducting a telephone snapshot survey and considering other available workforce data.
Final Report September 2009 21 Better Support for General Practice The low uptake of general practice training is a trend occurring across Australia. Applications to GP training schemes have fallen for the last 10 years, relative to applications for other specialist disciplines. The trend away from general practice training is further documented by a recent report from the Organisation for Economic Cooperation and Development (OECD) [The full OECD Health Data 2009 Report is available at http://www.oecd.org/document/54/0,3343,en_2649_201185_43220022_1_1_1_1,00.html ]. In the past, Australia had achieved a reasonable balance between specialists and GPs. The trend away from general practice however, is now evident with Australia joining France, Finland and Hungary with a widening pay gap between general practice and other medical specialties. The international and national trends have been reflected locally in the poor uptake of GP training places in Canberra. For the past four years the local training group of Coast-City-Country Ltd has not had enough applicants to fill all the available places. This means that local applicants will be unable to practice in Canberra. At the time of writing, the Taskforce has received advice from the local GP training group, Coast City Country Ltd, that in 2009 the number of applicants for GP training has exceeded the available training places. This highlights the need to anticipate a continuing demand for training places in the coming years. It is the view of the Taskforce that training GPs locally is a key strategy for building a sustainable GP workforce in the long term. There is a need for an increased allocation of GP training places for Canberra.
The Taskforce acknowledges the ACT Government commitment to the general practice workforce and the funding announced in the 2009—10 Budget for a $12.2 million package over four years to support growing our own GP workforce. The funding will: support GPs in the provision of quality teaching and training opportunities for GP trainees from the ANU Medical School through infrastructure funding grants for their practices, and teaching incentive payments, continue and grow the ACT Prevocational GP Placement Program (PGPPP) which allows junior doctors to gain clinical experience in general practice, following the successful trial of this program, and Recommendations: provide Canberra region GP scholarships for third and fourth year ANU 2. Improve the uptake of doctors into general practice by implementing the medical students who will work in the region. following ACT Government 2009—10 GP Workforce Budget initiatives: These initiatives Teaching will be important Incentive forPayment supporting to support the future GPs teachinggeneral practiceundergraduate workforce. There are however,medical only students eight GP training places allocated to the ACT and without a significant increase in this number it is highly unlikely that the ACT will be able to train PGPPP that enables newly trained doctors to gain clinical experience in enough GPs to overcome the GP workforce shortage. general practice Scholarships providing incentives to choose training in general practice 3. Continue to work with the Australian Government and Coast-City-Country Training Ltd to establish more local GP training positions. 4. Support the ANU Medical School GP Student Network (GPSN) and other Final Report September 2009 22 student activities related to general practice. 5. Continue to support existing general practices through the provision of grants to encourage infrastructure and sustainable workforce. Final Report September 2009 23 Short-term Sustainability Overseas recruitment The Taskforce has heard that there has been a low uptake of available GP training places in the ACT. It has also heard that International Medical Graduates interested in working in the ACT are excluded from undertaking any training in general practice in Canberra because they are obliged by the Australian Government Department of Health and Ageing to train in a rural and remote region. This restriction impacts upon the pool of International Medical Graduate doctors that are able to be attracted to the ACT. The result is that an International Medical Graduate has access to a Medicare Provider Number in the ACT only in a District of Workforce Shortage and only if they have the Royal Australian College of General Practitioners (RACGP) qualification or equivalent. The second challenge is that a Medicare Provider Number is only available in the ACT if the International Medical Graduate is on a temporary visa, and not if or when they are awarded permanent residency. When an International Medical Graduate is granted permanent residency, they have to move to a rural and remote area to gain a Medicare Provider Number and work. While the Australian Government supports the employment of International Medical Graduates in Districts of Workforce Shortage, the Taskforce notes that provisions for outer metropolitan and Districts of Workforce Shortage need to be extended to cover the whole of Canberra (a full discussion of this is in the attached Discussion Paper).
Recommendation: 6. Work with the Australian Government to extend the District of Workforce Shortage provisions to the whole of the ACT, for at least the next four years or until the number of GPs in the ACT reaches the average per 100,000 of population for similar metropolitan regions and include those working toward Royal Australian College of General Practice Fellowship to have access to provider numbers in the ACT.
There are also a range of Australian Government workforce support programs and initiatives which are available to rural and remote areas but not the ACT. The Taskforce notes that figures from the 2005 Report on Government Services for the Full Time Equivalent workforce in the ACT during 2003-04 showed that the ACT had 198 FTE doctors for a population of 324,000 – a GP:Population Ratio of 1:1636. This figure was lower than other surrounding areas although it was more than Queanbeyan and district (whose population would also access ACT GP practices).
Attracting GPs to move to Canberra is the major short term strategy available to address our workforce shortage. However, the Australian Government rules covering where overseas GPs can work, seriously disadvantages the ACT. To achieve short term
Final Report September 2009 24 sustainability for the ACT, these rules should be reviewed. However, the ACT is also unable to compete with the incentives being offered to International Medical Graduates in other parts of Australia. These incentives include Australian Government subsidised relocation allowances, under the outer metropolitan provisions, which are only available in some parts of the ACT. Other incentives being offered around Australia include local councils providing housing and transport, especially in rural and remote areas. While the ACT offers the “Live in Canberra Campaign”, there are no incentives offered to GPs to move to the ACT, other than the provisions under the outer metropolitan scheme. Canberra is not competitive in the current market. The Taskforce heard that a low or interest free loaning scheme which provides incentives to establish new GP practices within the region is one option which could be explored.
While making the ACT competitive is one challenge, another challenge is making the process for GPs to move here easier. Procedures for International Medical Graduate to become registered and able to work in the ACT take over six months. Much of this time is taken up waiting for verification of documents and being assessed for registration purposes. The ACT Government has already provided funding to support a half-time marketing and GP support officer in partnership with the ACT Division of General Practice. However, compared to the marketing teams supporting regions with shortages comparable to the ACT’s, this falls well short of our requirements.
Recommendations: 7. Explore new and competitive incentives to attract GPs to relocate to the ACT, including the feasibility and efficacy of a low or interest-free loan scheme to encourage the establishment of new GP practices within Canberra. 8. Increase the GP Marketing and Support Officer role to full-time. 9. Focus strongly on Australian and overseas GP recruitment for the next four years.
Short to Medium Term Sustainability The Part-time Workforce As noted earlier in the report, the notion that part-time GPs have the capacity to work more to alleviate the GP workforce shortage has been challenged [Douglas K, Dwan K and Forrest L, ACT Sessional GP Project, in progress]. In 2008 the ACT GP Workforce Working Group commissioned a Sessional GP Workforce study (funded jointly by the Australian Government, the ACT DGP and ACT Health). A recent finding from this work is that there is limited capacity within the part time workforce to undertake more clinical sessions in typical general practice. Those who are part-time clinical workers were either engaged full-time through employment in non-clinical roles or have personal reasons for working part-time, such as carer roles or winding down for retirement. This
Final Report September 2009 25 finding does, however, highlight a marketing point for the ACT. The variety of employment opportunities within the ACT could be used to sell general practice as an interesting and diverse career.
Prolonging the time until retirement is our only other strategy available to achieve short term sustainability. While members of the Taskforce acknowledge that the older generation of GPs over 55 years of age may continue to work longer than they might have planned, as a result of financial losses in the recent recession and an inability to sell their practice, eventually they do cut back working hours and retire. What will be needed in the short to medium term are strategies that continue some level of GP engagement in the workforce. There are some possible strategies to support older GPs in their current practice, and some options to provide new ways of part-time work for semi-retired GPs in innovative service models —for example in aged care. However, the greatest challenge lies in attracting recent medical graduates to train in general practice and then encourage them to work in Canberra.
Supporting women GPs to participate in the clinical workforce is another possible short to medium term strategy. During the consultation, a number of women GPs raised childcare as a significant issue. Access to flexible childcare is a barrier for some women re-entering the workforce. There is a clear need for a systematic approach to meet these needs in order to sustain participation of GPs who take parental leave. It is likely that these GPs will eventually increase their participation in the health workforce once their children are old enough and it is critical that their skills and confidence are not lost during the early years of parenting.
Recommendation: 10.Market the ACT to GPs as a place of work choice and flexibility with employment opportunities additional to usual GP clinical work in government, education, research and innovative models of service provision. Create and publicise opportunities for GPs over 55 years of age to remain engaged in with work in general practice in the ACT.
Re-entry to the Workforce A number of women GPs also raised the challenge of re-entering the workforce. The Australian Government requirements around Medicare Benefit Schedule and the IT systems supporting general practice are changing rapidly (commonly referred to as “red tape”) and cause considerable concern amongst GPs. Any GP who takes time out from the workforce faces significant challenges in catching up with changes to the “red tape” and practice software during their absences. As one GP told us, “I’m put off going back because I am no longer familiar with the bureaucracy I need to navigate to do my job well.” There is clearly a need for a re-entry program to support GPs back into the workplace.
Final Report September 2009 26 Recommendation: 11.Support GPs taking parental leave to stay engaged in the clinical workforce by developing a suite of supports including access to childcare and provision of re-entry programs for GPs returning to the clinical work place.
Longer Term Sustainability
The long term future for the GP workforce in Canberra depends on creating a setting in which primary health care and the discipline of general practice is seen as a top priority for the community. To create service sustainability, we need to develop a whole of career strategy for general practice based on the needs of the workforce. The ANU Medical School, the Academic Unit of General Practice and Community Health, together with the local training group of Coast-City-Country Ltd and ACT Health already provide the platform for excellent teaching and learning in general practice. There is scope to build on the favourable foundations already in place to make Canberra and region the most highly regarded setting to study medicine for aspiring GPs. For this to occur, the excellent opportunities for “vertical” learning that are already available for medical students, pre-vocational placements of interns and GP registrars need to be strengthened and promoted. Canberra is already a national leader in teaching and learning for general practice at all stages of the medical career pathway.
The place of general practice and generalism could be enhanced within ACT Health by the creation of structures for the engagement of GPs in governance and clinical governance for evolving models of primary health care in Canberra.
As previously stated, at a political level ACT Government is well placed to engage with the Australian Government to put the case that the gap that is apparent between specialist and GP remuneration must be closed in order for newly trained doctors to be able to see general practice as a worthwhile training option. ACT Health is also well placed, because the ACT is small and has relatively few education providers, to create an interprofessional teaching and learning environment which is inclusive of medicine, nursing and allied health.
Non-medical GP Workforce Work undertaken by Dr Phillips’ team at the Australian Primary Health Care Research Institute shows that nurses working in general practice are the fastest growing part of the primary health care work force [Phillips, C. B., Pearce, C. M., Dwan, K. M., Hall, S., Porritt, J., Yates, R., Kljakovic, M., Sibbald, B., July 2009, Charting New Roles for
Final Report September 2009 27 Australian General Practice Nurses http://www.anu.edu.au/aphcri/Spokes_ Research_Program /Stream_Three/Phillips_abridged_25.pdf]. The number of Practice Nurses has increased by nearly sixty per cent since 2005 and there are now about 8000 Practice Nurses in Australia [ibid]. In their report, Phillips et al have found that general practice nurses play a pivotal role in easing the strain on general practitioners. General practice nurses make general practices more resilient and prevent burn-out among GPs —but not enough doctors and policy makers recognise their pivotal role. Phillips’ report highlights innovative and broad-based funding, improved career progression and indemnity insurance for nurses as strategies to help attract more nurses into general practice.
Currently, the Australian Government provides some funding to GPs in outer metropolitan areas to support the costs of employing a practice nurse. There is also support for particular nursing activities within the MBS. However, the Medicare nursing items focus on clinical activities. The potential contribution of general practice nurses extends beyond clinical care to incorporate education of health workers and patients, organisation and quality control [Dr Phillips, 8 July 2009 Media Release]. The Taskforce supports the view of Dr Phillips and her team that the Commonwealth Government needs to support continuation of the general practice nurse role which creates a career for practice nurses and ensures they are able to work to the peak of their capacity.
The emergence of nurse practitioner roles is starting to gain a footing within the ACT general practice community. These relatively newly established roles have created links between residential aged care, general practice and the emergency departments. Now, they are also emerging as supportive roles within the general practice setting. Two practices now employ general practice nurses who are undertaking masters level qualifications to become nurse practitioners in general practice. The ACT Government, the education sector and the primary health care sector need to work closely to develop the role of practice nurses at all levels of training. Canberra is well placed to take a national leading role in promoting and developing the role of nursing in the primary health care team and to include a vertical integration education model for nurses to increase workforce supply.
Allied health professionals also play a critically important role within the primary health care workforce. Some general practices already include allied health professionals in their practice environment to meet particular needs of the population they serve. With the movement towards multidisciplinary primary health care and nurse-led health centres across Australia, driven in part by new Commonwealth Government funding, there is likely to be an even greater need to create links between members of this evolving primary health care environment.
The information technological revolution is here, but is yet to facilitate comprehensive communication between the different parts of the health system. Both GPs and community pharmacists have told the Taskforce that a seamless service electronically
Final Report September 2009 28 linking community pharmacy to general practice across the ACT would be beneficial. Furthermore, Medicare Benefit Schedule arrangements associated with care plans could be automated to refer people to an allied health team—by building a community of primary health care practice. Automation of referrals within care plans may also have benefits for other members of the health professional team. It is well documented that there are workforce shortages in nursing and a number of allied health professions and better use of information technology has the advantage of reducing the non-clinical burden.
The Taskforce notes the $1 billion plus commitment in the ACT Government budget for Your Health Our Priority—the Capital Asset Development Plan to redevelop the public health infrastructure including for e-health, and ready the ACT health system to respond to growing health service demand through to 2022 and beyond. All Taskforce discussions with the community and the profession highlight the central role of general practice in the health care team and this will be an important consideration in the planning process.
Today a significant number of medium and large general practices employ a practice manager. As the world of primary health care becomes larger and more complex, this role has become pivotal in providing quality and safe health care. These roles will grow in their importance as general practices become larger with a predominantly part-time workforce.
The role of general practice receptionist is also critical to general practice. We need to encourage more people to choose to become general practice receptionists. Queensland has already begun to do this by making the role of the receptionist more interesting and valuable to the provision of health care. A TAFE based Medical Assistant Certificate IV has been established in Queensland which enables qualified receptionists to assist or relieve general practice nurses of some routine non-clinical duties.
Recommendations: 12.Request the Australian Government to extend the Outer Metropolitan Provisions to the whole of Canberra and thereby support all general practices to employ a practice nurse. 13.Work in partnerships with the education sector and general practice to develop a career pathway for general practice nurses, including nurse practitioners. 14.Work with stakeholders to explore the potential for new support roles such
Final Report September 2009 29 Summary
Based on current observations, the trend to feminisation of the GP workforce is not changing and it is likely that in the next ten years the general practice workforce will be substantially female. The Taskforce received representation from GPs, sessional part- time doctors and practice principals about the impact of parenting on availability for clinical work in general practice.
The most significant issue presented to the Taskforce for women GPs is finding suitable childcare to support them to participate in the clinical workforce. It is crucial that women doctors are supported in accessing quality, affordable and flexible childcare while their children are in the early years so that women GPs do not lose touch with their professional environment and training. Refresher courses for GPs returning to work after parental leave was also raised as a significant need, especially in relation to the rapid changes in practice software systems and Medicare arrangements.
There is also a critical need to establish the necessary information technological communication system to create a seamless system. The provision of primary health care will evolve in the next decade and it is likely that the role of interprofessional team work will become the key to sustainable service provision and best practice.
The role of support staff is going to become increasingly important as the make-up of general practice changes. ACT Government, the education sector and general practice need to work together to create career pathways for these workers, particularly for general practice nurses and medical assistants.
Final Report September 2009 30 Chapter 3 — Sustaining General Practice
Introduction
In the past few years general practice models of service delivery and workforce utilisation have been changing. The changing nature of general practice is in part due to the workforce shortage. Economies of scale and market forces have presented opportunities for corporations to develop practice models that typically offer GPs an opportunity to work without the burden of running a business in addition to being responsible for the demands of providing a clinical service to patients. New business models are impacting upon the locations and size of general practices across Canberra.
As already noted, some GPs approaching retirement have not been able to sell their businesses to younger GPs. Contract payments offered by the larger corporate practices are attractive both to newly trained GPs and those planning for their retirement. Many newly trained GPs do not see setting up their own business as attractive and are interested in a “walk in and work” model of care. Taskforce consultations have shown that there is a diversity of general practice business models with small, medium and large practices operating in ACT (see the mapping exercise included in the GP Taskforce Discussion Paper June 2009). The Taskforce heard that the ACT community values the traditional model of a small practice (less than four GPs) at the local shops, however, workforce pressures and the availability of work in corporate practices is likely to result in a continued shift towards larger practices at bigger commercial centres and at town centres.
The Taskforce received submissions during consultation in regard to the importance of sustainable after-hours GP locum services for Canberra. In 2005, ACT Health worked with the GP sector, the ACT Health Care Consumers Association and other major stakeholders to develop a model of after-hours GP care built on the existing Canberra After Hours Locum Medical Service (CALMS). This model has been very successful in attracting and retaining GP locums to provide support in the after-hours period. The provision of this after-hours service is a key factor in sustaining viable in-hours general practices. Without this service, those GPs who offer both an in-hours and after hours service are left sleep deprived which potentially impacts upon their service provision. It is also a critical component that enables general practices to obtain Accreditation, which is necessary to be eligible for a small but significant funding stream via the Australian Government Practice Incentive Payments (PIP). General practices need to use an accredited medical deputising service (such as the Canberra After Hours Locum Services) in order to obtain and retain accreditation. The Taskforce notes that a robust model of after-hours GP locum service, such as that currently provided by CALMS is critical for the provision and sustainability of all general practice services in Canberra.
Final Report September 2009 31 Evolving Service Models
During consultation, the Taskforce found a range of views on general practice models of service provision. Some GPs expressed interest in working in a model of primary health care that would provide them with salaried employment and secure terms and conditions. Some GPs expressed interest in working with a wider team of health professionals than the typical general practice can support under current business models. Several GPs expressed an interest in developing a model of primary health care that was akin to the team approach used in the Aboriginal Medical Services (AMS), with the local AMS, Winnunga Nimmityjah Aboriginal Health Service cited by many GPs as a good model of primary health care provision.
Views about the business model and clinical governance for primary health care teams were varied. Some GPs were highly supportive of a strong component of government involvement in a new primary health care service in the ACT. Others favoured a service that supported existing general practices to provide the medical care for patients with strong links from community based nursing and allied health making up the team. Several other ACT services were mentioned as examples of primary health care services providing team care, with a GP component for particular population groups. These services include the Althea Wellness Centre, run by Directions ACT for people affected by drug and alcohol dependency, Companion House, which works with people who have sought refuge in Australia from persecution, torture and war related trauma, the Youth Junction Health Service (provided by Anglicare) and the West Belconnen Health Co- operative, which has been supported by funding from both the ACT and Australian Governments.
In the 2009—2010 Budget, the ACT Government announced $51.3 million for an Enhanced Community Health Centre at Belconnen as part of the Capital Asset Development Plan (CADP) in which there is also funding to refurbish existing heath centres. Opportunities arising from the CADP include a chance to explore collaborative models of primary health care delivery. Other possible benefits may include enabling greater focus on health literacy and health promotion and an opportunity for multidisciplinary practice and learning to be incorporated into service delivery models. Recent experience from the UK suggests that if professions are trained in isolation from one another, graduates in these professions are less equipped to practice in an integrated environment. As part of a strategy with long term goals, teaching institutions could be encouraged to explore opportunities for team based learning within these new environments.
Taskforce consultations have also revealed some broad themes in relation to primary health care in Canberra. One theme was the range of service provision extending across the for-profit business model at the large corporate practice end of the scale; the medium sized private practice, which must operate cost effectively, and the not-for- profit practice that provides primary health care services for particular groups within the
32 Canberra population. At the not-for-profit end of the range, government provision of support through funding or in-kind, allows the development of a business model and a model of care that does not depend on all patients being seen by a doctor. At the private for-profit-end of the scale, a medical model is substantially encouraged as the practice derives most income from the Medicare Benefits Schedule and the fee for service arrangements. There are opportunities for new service models that promote flexible collaboration across the whole primary health care sector, adequately supported by appropriate e-health , human resources and innovative funding arrangements. One possibility could be to explore, in partnership with the Australian Government and higher education providers, the establishment of networks or communities of practice to foster collaboration, evidence based practice and interprofessional learning . The proposed communities of practice would support interprofessional activity at all levels of education and training Interprofessional communities of practice would be developed with strong health care consumer engagement and links with relavent community organisations.
Recommendation: 15.Develop and evaluate new models of primary health care service delivery which include a generalist medical component of care that would provide comprehensive primary health care to targeted populations otherwise unable to access usual GP services.
Health Literacy and E-Health
The Taskforce received submissions highlighting the need for a greater understanding in the community and amongst health care workers about available primary health care services. In addition, information about primary health care services needs to be readily available in various formats, languages and in various locations. The internet has the potential to support GPs and improve communication and networks across the health sectors. E-health provides significant opportunities to support team work, integration of services, evaluation and monitoring of the health care system. It can also potentially contribute through point-of-care testing, electronic decision support, home monitoring and improved communications. To effectively support team care and integration of services, systems need to be developed that allow for safe, seamless, and efficient electronic linkage of information between patients, carers and members of their treating team across the traditional “silos”.
The Taskforce notes the $90 million investment of the ACT Government to build e-health capacity and infrastructure for Canberra’s health care system into the future. The benefits of e-health include increased efficiencies, quality, timeliness, safety and productivity of the system overall. New information and communication technologies,
33 such as tele-coaching, are key components in addressing and managing the increase in demand for health services. The E-health Future Package could be supported by the new and redeveloped ACT community health centres, and includes: personal electronic health records that enable accurate and trusted personal health information that is available to the right person, at the right time to enable informed care and treatment decisions digital hospital and healthcare infrastructure to support a medical grade secure network to enable safe, timely and reliable exchange of sensitive clinical information by health professionals and provider organisations decision support which will include electronic medication management to ensure safe, accurate and timely prescribing and administration of medication, and online access to clinical protocols, guidelines and new medical research and support services that provide the infrastructure components of e-health that make decision support, personal electronic health records and the digital environment possible.
E-health has also been identified as an area for national work within the National Health and Hospital Reform Commission Final Report. It will be important for the ACT that any local development on an e-health platform is done in a way that will allow it to link seamlessly with any national platform. This will maximise the current investment by the ACT Government into the future. Additionally, the Taskforce considers that for the development of this work, a comprehensive provider directory of health care service providers and community service providers should be developed and maintained for the ACT and surrounding region. For this to occur, there will need to be sufficient allocation of infrastructure and human resources. It is the view of the Taskforce that developing and maintaining the provider directory is an essential step in contemporary health service provision.
Once established, the e-health platform will revolutionise work roles and the way chronic health care needs are managed by linking all the different parts of the system. The evolving concept of general practice as the “health home” will be promoted and supported by a universal health record and by voluntary enrolment for health care consumers with complex and ongoing medical conditions. There are also significant benefits for consumers as e-health should help consumers navigate the health system and encourage them to take a greater role in managing their own health care. The development of an e-health platform for a single health care record will require a process of collaboration founded on mutual trust and collaboration. It must be a comprehensive record that the person is able to read and feel that they own. The information also needs to be able to be read and added to from both the private and public health sectors and the health care consumer.
Recommendation: 16.Develop and maintain a service provider directory for Canberra and the surrounding region. 34 17.Work in partnership with stakeholders to ensure the centrality of general practice in the development of the e-health record. Red-Tape The Taskforce heard that a significant amount of GP resources and time, which could otherwise be used for patient care, is taken up by paperwork, complexity of service coordination and compliance issues. Furthermore, based on the findings of the Productivity Commission's interim report on General Practice Administrative and Compliance Costs in February 2003, the Australian Medical Association concludes that if the red-tape were halved, this could have a significant impact upon the current GP workforce shortages. There is a large amount of paperwork which GPs are also regularly requested to complete, including various kinds of medical certificates: standard private, Comcare, ACT workcover, NSW Workcover, University exemption forms, Third Party insurance forms and a plethora of Centrelink forms. For many of these forms, it is not a legal requirement that they be completed by a GP. Public education, coupled with increasing utilisation of practice nurses and practice staff with new roles within existing general practices, should be explored to reduce the burden of paperwork on GPs. Internationally and in other jurisdictions, for example Queensland, the role of medical assistants has been shown to be useful in supporting efficiencies in the provision of non- clinical services within general practices. The medical assistant role is provided by a member of staff with a TAFE Certificate IV qualification. There is scope in the ACT to provide this training and introduce this new role into the general practice team.
Of interest to the Taskforce is the outcome of the 2003 Commonwealth Government commissioned ‘GP Red Tape Taskforce’ which reviewed Commonwealth arrangements impacting on general practice administrative and compliance costs, and to develop strategies to reduce, simplify or eliminate these requirements [http://www.pc.gov.au/projects/study/gpcompliance/docs/finalreport]. The report made recommendations to streamline Commonwealth information collection, support for enhanced GP use of IT/IM, ongoing monitoring of GP administration costs and review of the PIP and EPC items. The Taskforce notes that there is still much work to be done to streamline the administrative burden in general practice and improve efficiencies in primary health care service provision.
Recommendation: 18.Strengthen links between the ACT Division of General Practice, the Royal Australian College of General Practitioners, the Australian Medical Association ACT, ACT Government, the Australian Government and other agencies to consider ways to address “red-tape”.
35 ACT Snap Shot As previously stated, the Taskforce is of the view that there needs to be accurate and up to date knowledge of practice locations. This knowledge is crucial for understanding pressure points in the community, including areas of Canberra that are clearly undersupplied with practices and also for effective planning and for the response to disasters such as bush fire and pandemic. From the information gained in the snapshot survey undertaken by the Taskforce, a number of other themes have emerged around size, accessibility, bulk-billing, and general practice nursing workforce.
General Practice Sizes The Taskforce has observed that there is the range of practice sizes in the ACT ranging from small (less than four GPs), to medium (four to ten GPs) and large (greater than ten GPs). As indicated, the Taskforce undertook a snapshot survey of general practices in the Canberra region and produced a visual representation of the geographical spread of general practices by their size, across the ACT. This work was achieved through a cooperative partnership with the ACT Planning and Land Authority and provides a reference point allowing trends to be monitored into the future [see the Discussion Paper].
The snapshot survey, which ninety-five per cent of general practices across the ACT participated in, shows that the distribution of GPs working within general practices across the ACT varies. At the time of the survey (July 2009), fifty per cent of general practices across Canberra are small, while forty-four percent are medium and six per cent are large.
The snapshot survey also provided other information including: whether practices were taking on new patients; which groups of patients could be bulk billed; how many practices had practice nurses working there; and whether practices have GPs who visit local residential aged care facilities. As a result of this fact finding and mapping exercise, the Taskforce concludes that some of the popular perceptions about general practice are not entirely accurate.
Access and Bulk-Billing It is often said that all practices have closed books but the Taskforce found that a significant proportion of practices were taking new patients. Just over a quarter of general practices were accepting any new patient into the practice and around a third were accepting new patients under certain conditions. The most common conditions for taking new patients were either to accept particular patient groups, for example only accepting university students, or that some, but not all GPs within the practice were taking new patients.
36 The Taskforce frequently heard that there is “no bulk billing” across Canberra. However, nine per cent of general practices surveyed bulk billed all patients for consultations, while sixty-four per cent of practices bulked billed under certain conditions. Another finding was that seventeen per cent of practices bulk billed for children under 16, while twenty-six per cent of practices bulk billed for people holding a Healthcare Card, and another twenty-six per cent bulk billed people with a Pension Card. The most common condition on bulk billing was the GP choosing to bulk bill on a case-by-case basis. Medicare data from November 2009 shows that the ACT has the lowest bulk billing rate at just over 50 per cent [http://www.medicareaustralia.gov.au/provider/medicare/bulk- billing.jsp].
Another finding from the snap shot survey was that fifty-six per cent of practices had GPs who visited their own patients in residential aged care facilities and eleven per cent had GPs who visited aged patients at home who were part of the practice and lived close by. There was a complex relationship between practices accepting new patients and practices that had GPs who visited their local residential aged care facilities. More practices had GPs visiting local aged care facilities if the practice was not accepting any new patients, compared to practices that had conditions for accepting new patients, or were accepting any new patients. There was no relationship between the number of GPs in a practice and the practice taking on new patients, their bulk billing policies, or the likelihood of GPs visiting a local residential aged care facility.
General Practice Nurse Workforce Another finding of the snapshot survey was that there are 35 part-time practice nurses and 25 full-time practice nurses working in the ACT. Interestingly, increasing numbers of GPs within a practice was associated with having a practice nurse—around half of small practices had at least one practice nurse compared to ninety-one per cent of medium sized practices and all large practices.
It would be useful to repeat this survey and consider additional questions as needed, on an annual basis.
Conclusion The Taskforce notes the diversity of general practice service provision in Canberra. Whilst some practices continue to operate in a traditional business and service model, there is scope for innovation and new models of practice, especially around improved interprofessional service delivery and team work. The recent ACT Government budget initiatives, Capital Asset Development Plan and recommendations of the National Health and Hospital Reform Commission Final Report, may provide significant opportunities for work in this area. The ACT Government e-health future package also provides opportunities to establish a virtual network of all the components within the health care team while also assisting
37 health care consumers to take a more active role in their care. As previously noted, the snapshot survey provides important information for policy, planning and service mapping and should be undertaken by ACT Health on an annual basis.
38 Chapter 4 — Strong Links and Liaison
Introduction Robust links are necessary between services in the primary health care sector to assist specific populations of Canberrans who experience considerable difficulty accessing general practice. A number of submissions, letters and consultation forums raised concerns about access to general practice for vulnerable populations and older people.
Vulnerable Populations
The Taskforce recognises that even the most articulate and informed consumer can be vulnerable in any particular encounter with the health care system due to power imbalances, perceived fear of retribution and because of their own state of health at the time of treatment. Clearly certain groups of consumers are especially vulnerable—for example disadvantaged children, women who have experienced domestic violence, the frail aged, Aboriginal and Torres Strait Islanders, those suffering from a mental illness, drug and/or alcohol addiction, people with a disability, those from culturally and linguistically diverse backgrounds, refugees and people re-entering society after a period of incarceration, the homeless and people seeking palliative care services who may be experiencing challenges accessing primary health services.
Active planning is essential to create structures that ensure that people with complex needs, who are unable to access primary health care and general practice through the mainstream channels, are assisted to overcome the barriers they face in accessing services. To make this a viable option, however, clearly defined access criteria will be essential.
The Taskforce acknowledges the excellent services of Winnunga Nimmityjah Aboriginal Health Service, Althea Wellness Centre, Companion House, the Youth Junction Health Service (provided by Anglicare) and the planned West Belconnen Health Co-operative, and many general practices that service vulnerable populations. However, not everyone with complex needs is eligible to access “population specific” services. There are significant numbers of people living in poverty, with chronic and complex health problems unable to access primary health care in suitable settings.
The ACT Government has demonstrated that taking a targeted approach to supporting general practice to engage with vulnerable populations such as people living with chronic and enduring mental illness is effective. As noted in the Discussion Paper, the Better General Health Program links people living with chronic and enduring mental illness proactively to general practices using nurse led coordination and service agreement payments between general practices and Mental Health ACT. This program
39 has shown measurable improvements in health for these people (blood pressure control, chronic disease management, PAP smear screening etc). This model of service provision could be an option for expanded access to primary health care for vulnerable populations currently unable to access general practice.
The Taskforce supports a model of improved access to primary health care for vulnerable populations that ensures access to existing general practice for the majority of people in need. The ACT Governments Capital Asset Development Plan will provide significant new infrastructure and could support accommodation and e-health for a hub and spoke model of care to link people with complex needs to practices through a collaborative service provided between ACT Health and Canberra general practices. General practices and other primary health care services could be engaged to form a virtual comprehensive primary health care service as proposed in the recent report of the National Health and Hospital Reform Commission.
Recommendation: 19.Support existing general practices to provide comprehensive primary health care to vulnerable populations in partnership with other relevant services. 20.Strengthen governance within ACT Health to support the practice of primary health care and the teaching and learning of general practice. 21.Promote Canberra and the region as leading the field in interprofessional teaching and learning for primary health care professionals with a strong emphasis on interprofessional team work and building communities of
Aged Care
The provision of care to older residents of Canberra especially those who are frail and house bound, and to those living in residential aged care facilities is an issue of the greatest concern to primary health care providers and to the community broadly. Whilst the snapshot survey of practices revealed more capacity than was believed to be present for standard GP care, the Taskforce heard repeatedly about the pressure on the aged care sector, and of the extreme difficulty faced by people seeking GP care in residential aged care facilities. This is a priority area for action.
The Taskforce was pleased to attend the Aged Care Forum hosted by the ACT Division of General Practice on 13 May 2009. At the forum, the pressures and stresses in the aged care sector associated with the GP workforce shortage were highlighted by GPs, representatives
40 from residential aged care facilities and from family members. The forum raised a number of important issues.
The Taskforce heard repeatedly at forums and through submissions of the misery faced by family members ringing up to 30 practices without being able to find a practice willing to care for their elderly relative moving into residential aged care. The Taskforce heard from the staff of Canberra’s residential aged care facilities about the stress of trying to get GPs to care for new residents and the difficulty of getting timely care for people who have an identified general practice. They told of times when the only avenue left to them to access health care was via the emergency departments. This is clearly not a sustainable option and timely access to in-hour GPs with the capacity to respond to the need of people of residential aged care facilities is urgently required.
Of particular concern were the submissions and comments received by the Taskforce from GPs very troubled that when they retire no other GP will take on the care for the patients that they currently care for in residential aged care facilities. This raises a significant challenge—GPs that are looking after the population of Canberrans living in residential aged care facilities are themselves ageing. Several GPs said that while they were likely to stop working in typical practice and their businesses would close, they would be prepared to continue to work providing primary health care to people of residential aged care facilities. For this to occur however, a business structure and model of care would be needed that allowed them to provide clinical services without the added burden of running a business. The Taskforce also heard from GPs that it would be beneficial if all residential aged care facilities provided suitable facilities for GPs to visit residents including a designated consultation room. Many GPs noted the need for comprehensive an e-health record to support all aspects of care provision in the residential aged care setting
The Taskforce is of the view that a primary health care service for people living in residential aged care facilities is the biggest issue for the ACT in relation to GP services. This is the part of the health care sector that will buckle first as a result of the GP shortage. The Taskforce acknowledges the recent ACT Government budget initiative to provide an In Hours Locum Service to support GPs already providing care in residential aged care facilities. The in-hours-locum-service may well support existing service provision and give encouragement to GPs who already provide care to patients in residential aged care. The Taskforce also heard that the role of nurse practitioners in the Rapid Assessment of the Deteriorating Aged at Risk (RADAR) service provided by ACT Health is useful in supporting residents of aged care facilities and GPs.
An important observation by the Taskforce is that the primary health care provided to people in residential aged care is not spread evenly across the GP workforce—it is a small proportion of the workforce providing the care. One of the reasons offered for this by several GPs is that the MBS rebates for primary health care in residential aged care
41 are inadequate and many consultations are bulk billed. Aged care is viewed as a very unprofitable area of general practice. If an adequate primary health care service is to be sustainable into the future, the remuneration issue must be addressed.
Recommendations: 22.Build capacity to provide primary care services to people in residential aged care facilities by developing a new aged care service that supports existing general practices, as well as allowing GPs who wish to specialise in providing services to older people, to work in a new model of service provision. 23.Roll out the in-hours locum service to support GPs and residents of residential aged care facilities.
42 Transport
The Taskforce heard that access to general practice is currently an issue for people who are unable to drive. As the population ages, the number of people who are no longer able to drive will increase. A component in the mapping exercise undertaken by the Taskforce included a comparison of the location of bus stops and general practices. Although many practices are close to bus stops, people who are sick, frail, disabled and elderly may find walking even relatively small distances an insurmountable challenge. When new practices are being proposed, planning around the location of public transport bus stops must be an important consideration.
Two ACT Government funded transport services are available. These include the Home and Community Care (HACC) service and the regional community bus service. Some people have raised concerns around waiting times for pickup and drop off. The capacity of these services to deal with the potential increase in demand associated with the ageing population and the economic down turn needs further investigation, including the proposal for shuttle bus to help transport people from large bus interchanges to the hospital. It would be helpful if the criteria around accessing these services were publicised more widely. It would also be useful if a number of key performance indicators (KPIs) were routinely measured, including the time a user waits for pick up and drop off. This would assist in future service planning. Currently public transport systems and community transport systems operate independently of each other with limited cohesion. The ACT Sustainable Transport Action Plan 2010 – 2016 is currently being developed and presents an opportunity to explore models of public and community transportation that provide a more cohesive and effective overall transportation system. The Taskforce therefore proposes the following recommendations.
Recommendations: 24.Ensure that in the Sustainable Transport Action Plan 2010 – 2016 provisions are made to manage the projected increase in demand for transport to and from health care appointments, including the establishment of bus stops and shelters directly outside any new general practices as part of the Sustainable Transport Action Plan 2010 – 2016. 25.Clarify and publicise the criteria around accessing Government funded community transport services. 26.Recommend improved communication between regional community services who provide both HACC and community bus transports.
Conclusion The most urgent area for action in the provision of primary health care is aged care. New models of care based upon the existing skills in the GP sector and upon the existing
43 MBS provisions need to be devised and implemented soon. New models to provide primary health care services to people living in residential aged care facilities must be developed to ensure sustainable service provision. Failure to act swiftly in the provision of innovative service models would, in the view of the Taskforce, lead to many more people presenting in Canberra’s emergency departments, with serious consequences for both the individual and Canberra’s entire health system.
Chapter 5 —Records: access and legislation
Introduction The community values the traditional model of a small (less than four GPs) practice at the local shops. However, in recent years, workforce pressures and the availability of work in corporate practices has resulted in some smaller practices closing and merging. There is a trend towards practices located in town centres, with fewer traditional suburban practices in smaller shopping centres. When practices close or merge, the storage and availability of a person’s health care record is a significant issue that is governed by the Health Records (Privacy and Access) Act 1997. It became apparent to the Taskforce that the provisions under the Act in relation to notice of practice closure and arrangements for access to health records are not well understood—either by the community in general or the medical profession.
Access and Legislation
The Taskforce heard that recent mergers and closures of general practices, and the circumstances in which those mergers and closures occurred, have caused significant concern and disruption to the local community.
The recent events have also highlighted some areas in which the current legislation could be strengthened or clarified. These areas include; requirements around notice of practice closures and mergers, storage and transfer of health records, charging fees for access to health records, and the possibility of keeping an up-to-date list and map of GP practices.
In the Discussion Paper, a number of recommended legislative changes were proposed for consideration. Feedback through consultation with the profession and the community raised the importance of educating health professionals and the public around access to medical records rather than introducing penalties as a means to compliance. The Taskforce is supportive of this approach in the first instance. The Taskforce therefore proposes the following recommendations.
Recommendation: 27.Easy to read guidelines are developed and distributed for the community and the profession explaining rights and obligations in regard to access to 44 health records under the Health Records (Access and Privacy) Act 1997. Recommendation: 28.Current legislation be amended to: Mandate a period of four weeks notice to consumers and the community before closure or mergers of a practice can occur with examples of appropriate ways to notify the community. Allow the general provisions for consumer access to health records be extended to closure and transfer of practice. Remove the three week restriction in Principle 11 to allow records to be transferred immediately when required and include provisions that allow a practice to prioritise the transfer of health records, e.g. releasing records for current patients before past patients. Include an appropriate period of time for a record keeper to transfer a health record to another service provider when requested by a consumer. Clarify the status of e-health records. Provide that the current fees for access to health records be extended to the transfer of health records on closure or merger of a practice. Introduce a mandatory requirement that on closure of a practice health practitioners notify the Health Service Commissioner (HSC) regarding where the health records are to be stored. Current fees for health records transfer are extended to the transfer of
It became clear to the Taskforce that the role of the HSC in relation to health records is poorly understood by the community and the profession. Several submissions during the discussion period suggested more education and training of the community and health professionals on their obligations and rights relating to health records is required. The Taskforce sees a need for the clarification of the role of the HSC in this regard.
Further consideration and discussion is needed around the proposal to introduce a mandatory requirement that on closure of a practice, health practitioners notify either
45 the HSC or the relevant Health Professional Board regarding the location of stored health records. Further consideration is also necessary around a mandatory requirement for general practices to notify a relevant government authority when they open or close their business, to assist with coordination of policy and planning, particularly in relation to emergency response activities. Therefore the Taskforce proposes the following:
Recommendations: The roles and responsibilities of the Health Service Commission (HSC) in relation to health records are clarified and publicised to the community and the profession. Introduce a mandatory requirement for the notification of GP practices to a relevant government authority to be activated when a practice opens, closes, merges or transfers.
Conclusion The Taskforce notes that the current uncertainty around arrangements for notification of general practice opening and closure results in inconsistent information about general practice locations in Canberra with resulting confusion and inconvenience to the community. As it is likely that movement and closures of general practice will continue for the foreseeable future, legislation should be amended to improve access to health records and clarify the requirements for notification regarding the opening and closure of general practices.
46 REFERENCES
Douglas K, Dwan K and Forrest L, ACT Sessional GP Project. – Work in progress.
Douglas, K., Rayner, F., Yen, L., Wells, R., Glasgow, N and Humphreys, J. 2009, The Medical Journal of Australia. Australia’s primary health care workforce — research informing policy, 191 (2): 81-84.
GP Taskforce Discussion Paper June 2009 at http://www.health.act.gov.au/c/health? a=da&did=10010771&pid=1245368728.
Medicare Australia accessed July 2009 at http://www.medicareaustralia.gov.au/provider/medicare/bulk-billing.jsp.
OECD Health Data 2009 Report. 2009. http://www.oecd.org/document/54/0,3343,en_2649_201185_43220022_1_1_1_1,00.html.
Phillips, C. B., Pearce, C. M., Dwan, K. M., Hall, S., Porritt, J., Yates, R., Kljakovic, M., Sibbald, B., July 2009, Charting New Roles for Australian General Practice Nurses. http://www.anu.edu.au/aphcri/Spokes_ Research_Program /Stream_Three/Phillips_abridged_25.pdf.
Australian Government, Report on Government Services 2009, http://www.pc.gov.au/gsp/reports/rogs/2009.
National Health and Hospitals Reform Commissions report, A Healthier Future for All Australians Final Report June 2009. see http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report.
Health Records (Privacy and Access) Act 1997.
47 APPENDIX 1 – List of Submissions
1. National Disability Services 2. Carers ACT 3. Professional Management Solutions 4. Directions ACT 5. Tuggeranong Community Council 6. Health Services Commissioner 7. Heart Foundation 8. ACT Council of Social Service Inc. (ACTCOSS) 9. Ms M 10.ACT Department of Disability, Housing and Community Services (ACT DHCS) 11.Doctors4tuggeranong 12.Mr & Mrs H 13.Women's Centre for Health Matters 14.Health Care Consumers Association (HCCA) 15.HealthCube 16.Australian Indigenous Doctors’ Association (AIDA) 17.Ms H-C 18.Mr R 19.Ms C 20.Ms K 21.The Pharmacy Guild of Australia 22.ACT Division of General Practice 23.Dr L
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