It’s time for the fourth wave of general practice

  18 May 2020  Dr Ines Rio   

By Dr Ines Rio, Chair, AMA Victoria Section of GP and Chair, North Western Melbourne Primary Health Network.

This article originally appeared on the AMA Victoria website.

GPs are uniquely well-placed to help treat an Australian health system beset by rising costs, soaring rates of chronic disease, an ageing population, rising inequity and access problems. GPs are the first point of contact for the vast majority of interactions with the health system; and demand is only growing.  

GP visits were up 18 per cent in the 10 years to 2017, while in 2017-2018 some 88 per cent of Australians – 9 in 10 of us – visited a GP, with the average Australian going to their GP seven times per year. 

Within their general practice team, GPs treat and manage more than 90 percent of all the problems with which patients present. The decisions we make and the type of care we provide are fundamental to achieving the best outcomes for both the patient and the system.  

However, at the risk of stating the obvious, as GPs we can’t, by ourselves, manage every problem of every patient. With increasing complexity and chronicity of problems and therapeutic interventions, we require other practitioners and systems to work with us collaboratively around a patient, carer and family to achieve the best health outcomes.  

To take one of many examples, a key priority in Australian health care right now is reducing avoidable hospital admissions. The Australian Institute of Health and Welfare found that in 2016-17 there were more than 700,000 preventable hospitalisations – in other words, around six per cent of admissions could have been avoided by, “Timely and appropriate provision of primary or community-based health care”. 

Each of these preventable hospitalisations represents a significant cost. There is not just the expense of inpatient treatment, which is many times higher than community care, but the days and hours of lost productivity, the strain on hospital capacity and the unnecessarily prolonged pain and suffering for the patient themselves and their family. Better primary care, whether that is improved management of chronic conditions or timely treatment of acute illness, would be an enormous benefit for us all. 

So what do we need to do to make it happen? Australian medical training is already first-class and our GPs do not want for ability, care or commitment. What they lack is the opportunity to do their jobs in the best way possible. To spend the time they need listening to their patients and reading between the lines, looking for and managing the underlying causes of their condition and getting to know them as people, not as a collection of diseases. Giving patients that opportunity calls for a rethink of how we structure, fund and support primary care. To do that, I believe it is time to embrace a model that I call the ‘fourth wave of general practice’. 

As I see it, the first wave was the traditional doctor, a generalist who often worked in isolation treating a wide range of ailments that were usually acute. The second wave started in the 1970s, with the family medical program that led to general practice becoming a specialty in its own right, and this led to the third wave of larger practices and multidisciplinary teams. Now it is time to take this to the next level, with the fourth wave –the patient-centred medical home becoming the bedrock of the provision of health care. 

The evidence-based medical home model puts the patient in a partnership with a nominated GP in the middle of a connected suite of services that expand and enhance what a GP alone can offer. Several Primary Health Networks (PHNs) are already helping practices that want to move in this direction, with initiatives such as supporting quality improvement and the use of actionable data, embedding non-dispensing pharmacists in clinics or the Strengthening Care for Children pilot conducted by the North Western Melbourne PHN. This project looked at the impact on child health and the ability to care for children in the community by general practice by providing GPs with dedicated and timely specialist support from Royal Children’s Hospital paediatricians. Results showed a greater confidence in GPs in treating children, improved trust from families and a reduction in hospital outpatient and emergency referrals. 

It is important to understand that moving to this ‘fourth wave’ is an urgent need and not an abstract one. At a time when the complex care needs of the community mean the need for GPs is greater than ever, and the demographics of the profession means we are facing an imminent wave of retirements, fewer and fewer medical students are opting to specialise in general practice. Since 2015, there has been a 20 per cent drop in students applying to study general practice and in 2019 there were 63 first-year GP training places left unfilled, despite multiple recruitment rounds. 

The reasons for this range from the perceived lower status of general practice compared with other specialties to the very real gap in remuneration and conditions, which is only likely to grow under the current Medicare model. We need to be able to offer general practice registrars a more financially and professionally rewarding environment, where they are not forced to churn through patients, are supported to achieve outcomes and are properly compensated for the non-face-to-face time they invest in patient care. We need to be able to remove these negatives in order to showcase that general practice really is the most interesting, rewarding and valuable of all the specialities. 

What we must do is preserve and build upon the historical privilege that GPs have enjoyed – the capacity to have a three-dimensional view of the person they are treating, to deliver all-important comprehensive, coordinated continuity of care. The cost of getting it wrong will be high, both to the budget bottom line and the health of all Australians.