An investigation of the challenges facing primary care doctors around the world highlights plenty of lessons for Australia, reports health policy analyst Dr Lesley Russell.
Lesley Russell writes:
The respected, New York-based Commonwealth Fund recently published a new report, Primary Care Physicians in Ten Countries Report Challenges Caring for Patients with Complex Health Needs.
Australia is one of the ten countries examined, and the report’s findings present challenges to governments, policy makers and professional bodies to deliver improvements in a number of areas.
- the future training and support needs of GPs;
- the ability of Primary Health Networks (PHNs) to cope with the increasing expectations about the range of services they will be required to commission and delivery;
- improvements in communications between healthcare professionals, especially those that involve transfers of care; and
- better coordination of community-based healthcare and social care teams.
This report highlights that, compared to similar developed countries, Australia currently lags in a number of important areas.
The increasing load of patients who need ongoing care management for a number of co-morbidities, together with community and social services and episodic acute care, is putting increasing job-related stress and administrative burdens on GPs and their practices, and leading to concerns about the quality of care.
Failure to attend to these warning signs will have adverse consequences for the ability of chronically ill patients, including those with mental health and substance abuse problems, to be managed in the primary care setting and will impact the ability to attract and retain the best healthcare professionals, especially GPs, to primary care.
It is encouraging to see that 85 percent of Australian GPs surveyed say that their practices are well prepared to manage patients with multiple chronic conditions and complex needs.
However, fewer than half of practices are well prepared to manage patients needing palliative care (48 percent), patients with dementia (46 percent) and patients needing long-term home care (47 percent) and social services (41 percent).
Even as the Australian Government is looking for PHNs to do more in managing mental illness and tackling substance abuse, the Commonwealth Fund data highlight how unprepared many GPs are for these roles.
Only 34 percent of GPs surveyed said that their practices were well prepared to manage patients with mental health problems, and an even smaller percentage (19 percent) felt they were capable of managing patients with issues relating to substance misuse. Yet depression and anxiety are frequent co-morbidities with chronic physical illnesses, as is self-medication through the inappropriate use of alcohol and prescription medicines.
So perhaps that high rate of ability to manage chronic and complex patients is about their medical needs (treating their diseases) rather than their needs as a whole person?
This is borne out by other findings. While 75 percent of Australian practices report they have a nurse or a case manager to help manage the needs of chronic and complex patients, only 25 percent of these make home visits. Only 29 percent of practices routinely communicate with home care providers about patients’ needs and services. Australia has a comparatively low rate of after-hours practice arrangements, which means patients are more likely to end up in the Emergency Department.
The official response to this will almost certainly be that busy GPs don’t get paid, or don’t get paid enough, to do these additional tasks. But they are essential (and even cost-effective) for the care of older, sicker patients and so must be seen by those charged with service delivery and financing as an integral part of healthcare.
Another integral part of healthcare is the handover of care responsibilities between professionals and between sectors. Such transfers of care are well-recognised as danger zones where things can go wrong.
Yet only 58 percent of Australian GPs report that they get timely and useful information back when they refer their patients to see the specialist and only 18 percent are always notified when a patient in their care is discharged from hospital or seen at the Emergency Department. (It is interesting to note that the Commonwealth Fund report describes PHNs as “bridging the gap between primary and acute care”).
Some of this is because the e-health system is not sufficiently functional. Although 92 percent of GPs routinely use e-health records, this is really IT at the level of the 1980s – individual computers without the capacity to talk to each other.
Actual use of e-health systems to deliver reminders and exchange information is limited, with little improvement noted since this issue was last canvassed in 2012. There is little ability for patient to email their GPs and download or transmit information from their medical records.
Tackling these issues is not and should not be the responsibility of GPs alone: it requires a team approach incorporating an appropriate array of clinicians (including specialists), outreach workers, pharmacists and home care and social workers. It will require increased resources and finances for these teams.
But it will also require different training regimes and an examination of scope of practice so that all team members are used appropriately.
Failure to make these changes and others in a timely fashion will have consequences for healthcare quality. Currently only 48 percent of GPs think the Australian healthcare system works well, with only minor changes needed. Most think that the quality of care for patients has not improved in recent years – although more think it has improved (24 percent) than gotten worse (18 percent).
The strain of work in an inefficient system that is not geared to the healthcare needs of the 21st century will make retaining doctors more difficult. Only 12 percent of Australian GPs report dissatisfaction with practising medicine (only Norwegian primary care physicians report a lower dissatisfaction rate, compared to more than one-third of doctors in Germany, UK and US).
But 21 percent find their work stressful and a similar number are burdened by administration tasks.
The Commonwealth Fund report concludes that “Policy makers will .. need to maintain a commitment to iterating on new models for improvement, refining them, and evaluating their effectiveness with the patience to recognize that a successful recipe may not be immediately apparent.”
The advice is directed at the US, but can equally be applied in Australia.
(Researchers analyzed survey responses from more than 11,000 primary care doctors in Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Response rates ranged from 19 percent in Germany to 47 percent in Sweden. More details are here.)
• Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Heath Policy at the University of Sydney.