22 September 2017 Dr Ayman Shenouda Influence or overload We spend a lot of time trying to influence policy makers around what’s best for our patients. Advice which is always well-intentioned and usually offering the right policy fix, GPs work hard to influence and bring about positive sector change. We are passionate advocates for the patients and families we care for. Too often we see for ourselves the impact poor policy has on people’s lives. The solutions mostly lie in the evidence-based care that informs our everyday practice making us important policy participants. a political perspective, it must be quite hard being on the receiving end of all this advice. Having to work through submissions from every health organisation in the country with their list on how best to fix it. Sifting through the detail trying to find some common ground against their own checklist of whose voice beckons their closest attention politically. Then trying to work through the conflicting areas of advice, where the bias may lurk, to find the most workable solution. What’s really in the message? The Political Alerts allow us all to participate in this spectacle checking online what each has had to say. If you’re like me you sit back and try to see if there is alignment in any of it. Next, comes the quick filter on who’s come up with the best response to the actual issue at hand. The media too has its favorite. The go-to spokesperson on just about every health issue that impacts the sector. Not always the actual peak or expert on the issue either and for those at the grassroots the message sometimes seems a little apart. But then those real issues are just reduced to sound bites and random visuals if there is time around the spokesperson. In the end, the message is either oversimplified or reduced and likely to confuse. Unfortunately, there will always be that competing tinges leaving an identifiable stain that prioritises first the organisation it represents. This almost always comes through and sometimes only subtlety but easy to spot for those within the system. Finding common ground Perhaps this could be made so much simpler – not only for the policy maker but in terms of outcomes – if we just came together as a united group and settled policy first. This is not to say that collaboration doesn’t occur around issues. It does and usually at the highest levels. There are a number of unifying structures in place: The Council of Presidents of Medical Colleges, United General Practice Australia and of course on rural issues, the National Rural Health Alliance. Often finding that common issue or cause is not all that hard. We already have it and it lies in patient centred care and that focus in primary care is what unites us. But this simple message becomes distilled when there are parts of the system vying for their space, sometimes even survival. Primary care and collaboration Primary care is just one of those areas where we can’t afford to lose focus. It is a sector, which relies on teamwork. We already collaborate well by working together to share our expertise or to find ways to integrate for stronger outcomes but we can become easily undone by professional interests. Over the past two decades, I have been involved or have been a director of a number of peak organisations involved in primary care. Obviously, an organisations first priority will always be to make sure it is able to achieve its own goals and aspirations. As a director, you learn to work within these boundaries. But these organisational-level priorities sometimes make collaboration more difficult. Some strategies for collaboration For collaboration to work, respect and trust are key. Quite often it is the lack of trust among organisations in terms of intentions, which makes it so much harder to find common ground. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up to it. It’s also important to look to the other influences that help us collaborate. Take the time to build the relationships that support collaboration. This often means to value and embrace difference and healthy conflict. There can be great value from opposing points of view in terms of finding new solutions to tired problems. We should also challenge the status quo together so no one has to face difficult change alone. And always strive for win-win outcomes where possible. Finally, strong interpersonal skills among leaders are important to build the collaboration required to influence change. Coalition building More effort in bringing together the right mix of people to respond to issues impacting on our sector would support stronger outcomes. We have such a great diversity of talent within primary care which can be tapped into relatively easily bringing stronger depth to so many issues. Sometimes referred to as coalition building it is about forming coalitions with those holding similar values, interests and goals to combine expertise and resources for a common purpose.[1] In our case it is about having a ready-made alliance structured around targeted areas of expertise or the various issues our sector is likely to face. It is well understood that a broad-based, grassroots coalition enhances credibility. Bringing together diverse participants with similarly diverse skillsets and access to target populations for stronger reach makes sense. Encouraging broad participation also ensures we can bring new ideas and fresh energy to an issue.[2] These types of strategies help bring a united voice to an issue. We should be supporting each other across issues that impact on primary care as a whole – at both the local and national levels. It would be great to start a discussion around this and we can start now. I’d be interested in your views around how we might be able to better facilitate these types of policy alliances in the future. We’re better together The whole is greater than the sum of its parts. It’s quite simple. I think most working in primary care would consider that the whole is greater than the sum of its parts. First coined by the philosopher Aristotle, I love this phrase as it reminds us that we are better when we work together. And I really think that should guide our future policy contributions, particularly in primary care. It’s not always easy to implement but I think we need to get much better at it. It’s really just a case of an overcrowded agenda, which needs uniting or risk being overlooked. We most certainly need a united front in primary care. [1] http://www.beyondintractability.org/essay/coalition_building%20 [2]https://one.nhtsa.gov/people/injury/alcohol/Community%20Guides%20HTML/Book1_CoalitionBldg.html#Community%20Guide
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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] General Practice has faced many challenges over recent years –Medicare rebate freeze, new PHNs structure and recent changes in training delivery. All of these are impacting on the future of our profession. I believe General practice continues to evolve to meet the current and future challenges facing the Australian health system. However the College of GP’s has a pivotal role to support general practice to deliver an effective and sustainable healthcare for the communities they serve. This article is an attempt to explore and answer the question. How can the RACGP Add Value to General Practice? As general practice expands to meet the new environment and future challenges it is imperative to have a systemic approach backed by a solid business model that underpins quality care. There is also a need to support the creation of new models of care delivery as many of the RACGP members are either seeking the opportunity to open new practices or refine existing practices. I believe that the College can play an important role in supporting the business of general practice this will in turn support a sustainable and viable small business models regardless of whether you work in, or own it. The Australian health system ranks as one of the bests in the world I believe the strength of our health system lies in its reliance on general practice and the pivotal role of the general practitioner. I believe that it is essential that the solution for current and future challenges needs to come from within the profession by utilising the wealth of knowledge and expertise that exists within the College and its membership. This can position the RACGP as a leading voice in writing health policies and creating solutions alongside government. We also need to continue to actively promote and celebrate the role of GPs as highly trained medical specialists that offer solutions to address future complex health issues. We need to continue lobbying government and advocating for change to the funding models to close the gap between specialist and GP rebates. The strength of the College can only be realised by strong representation and engagement of its members. We need to create communication channels, which allow members to input ideas and concerns on key issues and provide a forum for expression of new ideas. Similarly, communication between the faculties and council needs to be enhanced. The College is privileged to have developed 9 faculties, each of which contributes important information and feedback on specialised aspects of general practice. Links between the colleges and sharing of information and practices can only serve to strengthen the workings of the College. To cope with the increasing complexity of issues and constantly changing primary care environment there is an urgent need to build leadership, which harnesses the individual and collective talents of primary health, teams. This requires proper engagement with college members by recognising potential leaders and fostering their talents through specific training pathways and mentorship. Research is the cornerstone of an academic college and the key to shaping our future practice. The general practitioner is in an ideal position to engage in research in primary care and help in the translation of new ideas and evaluation of interventions to the general public. There is a wealth of knowledge and research experience amongst our professorial members and Deans of General Practice, which can be utilised by the College. Our General Practices are a rich source for data collection, audit and real world experiences, which we need to encourage our College members as scientists to explore record and publish. Imparting the art of general practice is part of our responsibility in passing the baton to the next generation and instilling in future doctors a passion for the profession of general practice. Promoting career pathways in general practice in both rural and metropolitan settings is a key role for the College. We need to support training, education and innovative thinking through a wide variety of programs to enhance skill development at all stages of training. These are some of what I consider to be the key issues that the RACGP needs to engage with and I believe I have the experience in my past and present roles and the vision to lead the RACGP in the future to work alongside Council to add value to general practice. Ayman Shenouda |
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