 18 August 2017
Dr Ayman Shenouda Most will agree that high quality care in general practice relies on effective teamwork. There are some good studies providing insights into the key features of effective primary health care teams confirming a strong correlation between a good team climate within the practice and a range of aspects of high quality care. [i] A stronger focus on research within general practice, in my view, would provide more quantitative studies detailing the effects of integrated multidisciplinary teams from within the practice setting for differing health populations and geographic regions. From a broader health system perspective, there is currently strong interest on the efficiencies of multidisciplinary teams and their effectiveness in improving health outcomes and lowering costs. The role of the team in supporting integration between services and in enabling a shift from episodic to continuous care at a whole of system level. Driving this interest is also the need to develop new models of care in addressing increased demands associated with an ageing population and as the disease burden increases. The multidisciplinary team is best defined by Cohen and Bailey (1997) as ‘a collection of individuals who are independent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’.[ii] Therefore, ‘teamwork’, in this context, is the product of interactions between healthcare professionals in a team.[iii] Teamwork starts at the practice level My focus here is in establishing structures to support effective team interactions within your own practice first, providing ways to evaluate or measure success, which can then build toward broader integration aims. In measuring practice-level performance, teamwork in the primary care setting is often determined through a focus on a specific disease area such as effectiveness in terms of management of chronic diseases. Organisational capacity within general practice can also be tested through quality improvement measures such as through clinical audit.[iv] In my experience, clinical audit provides an effective way to measure the effectiveness of multidisciplinary teams in a value driven hole practice approach that aims to deliver quality patient care with clear achievable outcomes. Its participatory structure also allows you to ensure involvement from the full team in finding practical solutions. We know a much broader funding focus is required in terms of driving more effective ways to manage the increased complexities and costs associated with the new patient norm of multiple comorbidities and chronic diseases. Structural and system supports are required to enable coordination and collaboration across boundaries – primary, secondary and tertiary care. In order to truly tackle and address fragmentation and achieve a more seamless service for patients throughout their disease trajectory much more focus is required on ensuring the required supports at the practice level. Effective team characteristics Collaborative teamwork provides a link between efficient organisational practice and high-quality patient care.[v] A large cross-sectional study of Australian general practices undertaken in 2007 showed that team climate was important for patient and staff satisfaction. Interestingly, this study also found that in terms of large general practices, that separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.[vi] But how much do we know around the qualitative aspects of what makes for a well-functioning multidisciplinary team in the practice setting? One key study identified 10 characteristics underpinning effective interdisciplinary team work which is useful in terms of guiding a practice redesign. [vii] The 10 underlying characteristics of an effective team.
I agree that all these aspects are important to a well-designed and high functioning team. From my own practice perspective, I would attribute the most reliant performance factors around good practice governance and business management systems including clinical information systems in supporting integration. But a great deal of focus for us also lies in providing a supportive team environment and in strengthening the capacity of the team. Role utilisation and supports A practice can make a significant difference for its patient population by using the team to their full capacity. Greater use of the primary care practice nurse through nurse-led clinics has provided significant benefits in my own practices. Our nurse-led diabetes clinic is proving very effective in delivering this care. As are our COPD and other chronic disease nurse-led clinics through offering enhanced patient management of chronic and complex conditions by helping patients in managing their conditions. Nurse-led clinics not only lead to improved health care but can lead to patient empowerment as well as nurse empowerment. These models do not impact on continuity of care and instead provide a sustainable practice model enabling constant monitoring and management. Time intensive tasks such as data extraction, data management and patient recall systems in coordinating aspects of care are just a few examples which can be shared across the team. Exposure to the full workings of the multidisciplinary team can enhance the training experience for the medical student, prevocational doctor or registrar in the general practice environment. A culture of teamwork needs to be instilled early and can only enhance the learning experience for the trainee. They need to be immersed in this structure and fully exposed to the workings of the multidisciplinary team. It helps to improve their understanding of others’ roles and builds respect and understanding. Broader benefits for the entire patient population are achieved through stronger utilisation of the full practice team. Time efficiencies and cost benefits can be realised through increased throughput of patients. Patient booking can be made for both doctor and nurse, each with their own specific caseload and role but with a shared focus on enhanced patient care. The GP can then be better utilised in their specialist capacity to focus their expertise on more complex areas of care. Primary care service delivery models that optimise the performance of the full multidisciplinary team should underpin future funding decisions. This is a key requirement to shifting care to the more cost-effective sector of primary care and out of hospitals. Increased costs in addressing demand must be met through flexible funding solutions to help meet the additional cost burden for private practices. The effective use of skills to optimise the full practice team is key to providing patient centred collaborative care but the funding must now follow. Ends [i] Campbell S M, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study BMJ 2001; 323 :784 [ii] Cohen, SG and Bailey, DR (1997). What makes teams work: group effectiveness research from the shop floor to the executive suite. Journal of Management 23: 238–90, DOI: https://doi.org/10.1177/014920639702300303 [iii] Van Dijk-de Vries AN, Duimel-Peeters IGP, Muris JW, Wesseling GJ, Beusmans GHMI, Vrijhoef HJ. Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care. 2016;16(1):9. DOI: http://doi.org/10.5334/ijic.2454 [iv] Amoroso C, Proudfoot J, Bubner T, Swan E, Espinel P, Barton C et al. Quality improvement activities associated with organisational capacity in general practice. Australian Family Physician Vol. 36, No. 1/2, January/February 2007 8-84. [v] Mickan S, Rodger S. The organisational context for teamwork: comparing health care and business literature. Aust Health Rev 2000;23:179–92. [vi] Proudfoot J, Jayasinghe UW, Holton C, Grimm J, Bubner T, Amoroso C, Beilby J, Harris MF. Team climate for innovation: what difference does it make in general practice? International Journal for Quality Health Care. 2007 Jun;19(3):164-9. Epub 2007 Mar 2. [vii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19. [viii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
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 5 August 2017 Dr Ayman Shenouda Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well. We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i] The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii] But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue? Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing. At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii] From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply. The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv] But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage. The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution. Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v] The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi] Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii] This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii] In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners. General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs. While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered. [i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html [ii] Ibid. [iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy [iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404 [v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri [vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202 [vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/ [viii] Ibid.  In overcoming significant disadvantage, it is the capacity of the general practice workforce that will provide the biggest impacts in realising improved health outcomes over time. General practice is by far the most efficient and cost-effective part of the healthcare system. GPs are often relied on the most, particularly by those most in need and with complex and chronic conditions.
General practice is already an efficient part of the healthcare system. GPs also have a very large remit. In any given year, almost all Australians – or 85 per cent – will visit a GP at least once. Yet government expenditure on general practice is relatively low at around $6.8 billion, under 5 per cent, of total recurrent health spending.[i] When compared to the significant cost to the sector for hospital services - expenditure on public hospital services is at around $61 billion – general practice offers value for money.[ii] There is clear global evidence that health systems with strong primary care will secure long term efficiencies. Benefits from prioritised investment include achieving lower rates of hospitalisation, fewer health inequities and better health outcomes including lower mortality. The findings captured by Starfield for one make a convincing case for primary care investment and are not new, but so do so many studies that have followed it.[iii] [iv] A broader population health policy framework that recognises the role of primary care and general practitioners in addressing health disparities makes really good policy sense. But how do we convince our policy makers – firmly fixed within their short-term electoral cycles and need for quick wins - that a strong investment now will provide real and significant returns for a healthier future? It’s clear that policy makers are not short on evidence around the benefits of prioritising these areas. These are critical funding decisions that impact quality, access, and coordination of health service delivery. There is significant unmet need with access to primary health care still one of the main barriers to achieving equitable health outcomes. This is the case for many disadvantaged Australians and certainly for Aboriginal and Torres Strait Islander communities. National studies have shown that health outcomes improve with improved access to GPs in areas with relatively high predicted need for primary health care.[v] But we are not seeing anywhere near the level of investment needed to make the shifts required in supporting those most in need. Embedding more preventative health interventions in the primary health care setting also needs focus. Primary care and preventative health go hand in hand. A rising disease burden requires a stronger emphasis on preventative health and GPs are key in terms of delivery. We clearly need to be prioritising both areas and with the level of investment warranted to secure strong health outcomes. We need investment in both prevention and primary care with recognition through funding of the important role general practice has in delivering both aims. While preventative health requires a whole of community focus and an effort from each and every one of us, much of the service responsibility again falls to general practice. The GP has the lead role in ensuring their patients remain healthy over a lifetime and preventing illness, identifying risk and offering early intervention is already a large part of what we do. I know firsthand that our patients most certainly value general practice and understand well the need for prevention and for real investments around that beyond just a health message. Research Australia’s annual Health and Medical Research public opinion poll ranked preventative health as one of the nation’s key health priorities. More than 75 per cent of Australians ranked preventative health as a key priority in 2016. In determining health priorities, that role now falls to the Primary Health Networks and their focus in six priority areas: Aboriginal health, aged care, e-health, mental health, population health and health workforce.[vi] However, we know that issues around equity and social determinants of health is key to shifting entrenched disadvantage. The much broader set of objectives in our National Primary Care Framework (April 2013) should be revisited. Clear aims to drive our funding decisions which included a focus on addressing inequity in keeping all Australians healthy, preventing illness as well as reduce unnecessary hospital presentations and making improvements in the management of complex and chronic conditions.[vii] To drive the level of change general practice needs to be better resourced. Investment needs to prioritise general practice and build upon existing services and arrangements. An investment which will lead to improved health outcomes, better management of chronic disease, a stronger focus on prevention and lower rates of unnecessary hospital admissions. A strong investment in general practice is what is needed to secure a healthier future for all Australians. The lift of the freeze, albeit slowly, is welcomed, but this only puts us back where we were at in 2013 before it was introduced. Let’s get the full discussion back on track. Let’s pick up where we were at nearly a decade ago when we were on the cusp of significant reform in Australia. A reform which saw a priority on general practice and its role in prevention and primary care. [ends] [i] Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014–15. General practice series no. 38. Sydney: Sydney University Press, 2015. Available at http://hdl.handle.net/2123/13765 [ii] AIHW 2017. Australia's hospitals at a glance 2015–16. Health services series no 77. Cat. no. HSE 189. Canberra: AIHW. [iii] Starfield, B., Shi, L. and Macinko, J. (2005), Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 83: 457–502. doi: 10.1111/j.1468-0009.2005.00409.x [iv] Harris MF, Harris E. Facing the challenges: general practice in 2020. Med J Aust 2006; 185: 122-124. [v] Australian Institute of Health and Welfare. 2014. Access to primary health care relative to need for Indigenous Australians. Cat. no. IHW 128. Canberra: AIHW.http://www.aihw.gov.au/publication-detail/?id=60129547987 [vi] The Department of Health. Primary Health Networks (PHNs). Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Background [vii]Commonwealth ofAustralia.NationalPrimaryHealthCareStrategicFramework.2013.Availableat: http://www.health.gov.au/internet/main/publishing.nsf/Content/6084A04118674329CA257BF0001A349E/$File/NPHCframe.pdf  The passing of legislation during the last sitting days in June to establish a new National Rural Health Commissioner is a significant step forward toward achieving a more equitable healthcare service nationally. A new champion for rural patients, the role offers a new opportunity to ensure our collective voice is heard bringing to focus the important work we do. Through this key role, rural patients finally get the focus they deserve and we know that lasting change will require a broad policy lens encompassing all disciplines. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare. A focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies. Strategies which work to address access constraints in the context of diminished rural resources require supportive policy to enable integration. It is in developing these service solutions, through policy advancement, to support viable rural models of care that we can work together to address disparities. One of the first tasks for the new Commissioner will be to work with stakeholders to develop a National Rural Generalist Pathway. In maximising workforce outcomes, the ‘generalist’ role has long been the basis of rural medical practice enabling strong patient reach across settings to address access constraints. It is clear that rural GPs in utilising their broad scope to provide services across the continuum of care in a range of settings have always offered, and remain, a key solution to addressing rural patient need. But we are not working alone and this same level of focus is warranted across all disciplines to work to the level of service integration required. It’s reassuring that a much broader remit is envisaged by Dr Gillespie for the new Commissioner role. We all understand that addressing workforce and services issues to provide more effective, comprehensive healthcare is much broader than medicine. A focus encompassing nursing, dental health, Indigenous health, mental health, midwifery and allied health alongside medicine is required. The patient must also be given a strong voice and reaching out to the health consumer through collaborative community-led engagement will be important. To realise strong reform, a needs-based approach which can allow for flexibility is required. But it’s a hard sell. A community-led model or approach doesn’t always fit current funding models and our system does not always allow for the required integration. It is by working through the service mix required, both private and public, which are specific to local need and achievable against available resources, that communities can find the solutions they need. Removing barriers to enable multidisciplinary healthcare teams to deliver comprehensive patient care across rural settings is key to making this work. How to address increasing local demand for palliative care services, for example, needs a significant local commitment and many disciplines to make this happen. Working through to address poor service integration such as fragmentation which can sometimes occur due to policy barriers which limit the participation of allied health in aged and community care is another key example. We know what’s needed and what works well in rural. We’ve had years of review and it’s time to implement. Lasting change can only be realised through enabling more community-initiated solutions, adding flexibility to enable service integration. Finding local solutions in addressing need takes local leadership and time for critical planning which often needs to occur outside of practice hours. Support for this type of action can and will lead to improved skill utilisation and solutions which can work. It really takes a whole community - involvement by all sectors of the health community – to drive this level of change. In my own town of Wagga Wagga we certainly strive toward this level of engagement but in implementing new solutions our collective voice is not always loud enough. There is renewed hope that the new National Rural Health Commissioner can help us raise the volume enough for our community-led action to lead to change. [Ayman Shenouda]  A big part of securing the next generation of rural GPs is around ensuring there remains a positive focus on general practice.
Rural practice is challenging which in turn makes it very rewarding, enabling you to develop a breadth of skills to build resilience in addressing need. Providing that insight for future doctors in a supportive way during those early learning years is so vitally important. Sitting with a registrar recently, I was surprised to learn that he considered himself a rural generalist, and not a rural GP. This is despite the fact that he was training to a curriculum which is general practice: the endpoint in training for a rural generalist is of course a general practice Fellowship. Let’s be very clear: rural generalists are rural GPs. General practitioners are generalists by definition. The term ‘rural generalist’ describes a rural general practitioner working to the full scope of their practice with skill sets that are informed by the needs of the community they serve. These skill sets may encompass both advanced procedural and non-procedural skills working across primary and secondary care contexts with an emphasis on emergency medicine. It’s about ensuring the right skill mix against demand. The Federal Assistant Minister for Health, Dr David Gillespie MP, certainly knows this requirement well and his own definition is fitting: “A rural generalist is a doctor who’s trained as a general practitioner but has extra skills so that they can operate in a hospital setting as well as a community setting. That involves not just being a jack of all trades, but being a well-qualified doctor who can cope with the extra problems, clinical, public health, and hospital skills that you need to look after a regional town.”[1] It is the context that matters most and is key to getting health rural workforce policy right. The general (core) and advanced (specific) skills required in addressing patient need depend on the health needs and context of the community. That is why it is important we align training investment to service need. In developing a rural generalist pathway nationally, this, therefore, must also be broad. We need a national pathway that equips general practitioners with a full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. We know that developing skills around the ongoing care considerations are the areas that best serve the community. We also know that dedicated and clear pathways for rural GPs to acquire advanced skills and utilise them in a way that is valued and recognised are important workforce factors. Supportive strategies like these are vital in attracting and retaining a skilled rural workforce that is responsive to need. Most of all it’s about valuing the contribution to the healthcare system of quality general practice and its essential and enduring role in supporting rural communities. [1] Gillespie transcript. 29 March 2017. RDAA Poli Breakfast. Dr David Gillespie MP Federal Assistant Minister for Health. Canberra. |
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