Dr Ayman Shenouda
Despite having had the best policy intentions, we still have too many specialists, and too few general practitioners. The policy response has led to an unprecedented supply of junior doctors feeding a training crisis that will take many years to resolve. Here I’d like to share some ideas around how we can deliver a training model that prioritises need.
Making general practice more attractive
Ensuing graduates meet the needs of the community requires a new training model and approach.
It’s time for a rethink. If we are going to address general practice recruitment, we first need to deal with our image problem. We need to stop general practice from being a second choice. To do this we need to work through the problems in recruitment and this means doing thing very differently.
In making general practice a specialty of choice – we need to impart an early positive image which can then be backed by positive experience. Key to making this work is having more control as a specialty in ensuring exposure during those prevocational years.
Lost in the prevocational space
In increasing its attractiveness as a career choice for junior doctors we need to increase the status of generalism at all stages of medical education and training. It’s clear we are losing them in the prevocational space. It comes down to sufficiency of exposure to general practice and the need for specialty control at that point.
In getting them this exposure – which is currently intermittent – postgraduate medical curriculums need more focus on general practice and rural health. While there are now new programs to direct our efforts – the Hubs, RJDTIF and more recently through MDRAP - it is the uncoordinated decision making that will continue to limited our success.
The prevocational years remain problematic due to differing state arrangements dominated by hospital need and an underlying lack of ownership. The only consistency through the layers of complexity is the trainee. The funding needs to follow the trainee but we need to build in incentives to retain them on a specific pathway.
A collaborative approach led by the colleges of general practice and all organizations involved in those programs is urgently needed
There is also a need to formalise a supportive structure through funding the relationship between the trainee and the GP Colleges. This would support a key shift in establishing the relationship earlier, focusing on early identification and continuous support. It provides for the much-needed connection to general practice throughout prevocational and into vocational general practice training.
Remuneration is also important
GPs are overworked, undervalued and underpaid. We know that expected future earnings influence specialty choice with many choosing general practice following rejection of another specialty. In attracting more to general practice, we need to be able to compete with the higher earing specialties. The way we are paying registrars also needs to be reviewed. GP job satisfaction is also falling which further impacts on GP recruitment and retention.[i] The solution lies in the need to reform the funding model to prioritise primary care and generalism.
Funding for general practice
The current system devalues primary care. The government needs to be thinking seriously about funding for general practice. Income growth is impacted by decisions around incentives, the prolonged impact of stagnant Medicare reimbursement rates and a continued narrow focus on bulk billing. Significant new investment is required to enable longer consultations particularly in addressing chronic disease and factoring the real costs of delivering this care.
Flexible supportive pathway
The delivery of quality training through a flexible supportive pathway design needs continuity of funding. We need a long-term commitment that can continue to channel doctors into rural areas. We also need to change this perception that going rural means you have to stay rural forever. Enabling real flexibility of choice comes from building general practice training capacity in rural and remote areas to support the development of high-quality training.
Prevocational and postgraduate medical training also has to be aligned with the needs of the health care system. This means the incentives have to be aligned towards general practice and this needs to be led by the GP Colleges.
[i] Scott A. 2017. ANZ – Melbourne Institute Health Sector Report. General practice trends. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne.
New models of care: making integrated out-of-hospital care a reality
Dr Ayman Shenouda
As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities.
Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge.
We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions.
We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings.
For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting.
But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems.
This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care.
It is about bringing teams together consolidating different points of access to care and providing that care in the home.
This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery.
Hospital in the Home
Recently I met a doctor who is working hard to realise this vision for his community in Townsville.
Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital.
For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville.
Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups.
These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model.
Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital.
What makes the model work?
Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting.
Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion.
Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers.
It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home.
The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist.
These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment.
The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners.
The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills.
This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting.
Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services.
Hospital in the Nursing Home (HINH)
I believe a step-up approach within nursing homes is another way to apply this model.
The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care.
However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model.
We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital.
It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments.
Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home.
Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission.
But technology is only an enabler and we need to focus on investing in the model that underpins that technology.
In summary some key enablers for getting the model to work.
Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past.
Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key.
It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base.
Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need.
Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF.
The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult.
This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care. This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care.
It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there.
Whole care continuum
The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP.
Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home.
As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back.
We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality.
Building healthcare capacity in the Solomon Islands
Dr Ayman Shenouda
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
Health system challenges
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
The Good Samaritan
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
Most facilities are short staffed and without basic equipment. From Tetere it is one hour to Honiara for Xray or just to do bloods.
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
Improving critical care
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
What more can be done?
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
6 October 2017
Dr Ayman Shenouda
A focus on palliative care
There was some great discussion generated from my recent blog on frailty and ICU outcomes. The importance of patient empowerment and preference towards care in the community resonated with many. Palliative care is an important extension to that discussion. This is an area, which we know is expanding with demand which is set to rise alongside disease rates and an ageing population. Despite a stronger national focus on palliative care, the patient’s preference for community care is not translating into policy.
Palliative care should improve the quality of life of patients with an active, progressive disease that has little or no prospect of a cure. More and more we’re seeing patients’ preference for palliative care in the home. We know that 70 percent of Australians would rather die at home than in hospital. Whatever the choice, the model of care must enable access to all patients facing a life-limiting illness. We know that those who would get the most benefit from palliative care often accessed it too late. There is still so much in this area that we need to fix. I think a good place to start is ensuring our patients’ preferences around dying at home.
Access and choice
In finding a way through the system to facilitate choice for more community-level care we are still a long way from enabling equitable access. Early access to palliative care services is an internationally recognised policy goal. However, it is clear that our shared policy goal is not being met in Australia when it comes to access and choice.
This highlights our first policy failure, which is around equity in access which of course stretches beyond just palliative care and can be persistent throughout life for some most in need.
Where you live and your socioeconomic status has some bearing on choice in terms of preference of setting in palliative care. AIHW 2014-15 data released early in the year showed that there is a higher proportion of palliative care-related hospitalisations (22.4%) in the lowest socioeconomic status areas. The rate of palliative care-related public hospitalisations was also highest for those living in these areas (30.9 per 10,000 population). Conversely, the rate of public palliative care-related hospitalisations was lowest for those living in the highest socioeconomic status areas (14.5 per 10,000).
Funding and policy context
Funding and policy context really matters here. This is because funding models clearly influence service provision and the development of palliative care services. Funding for palliative care involves a mixed system of public, private and charitable players. A mismatch between policy goals and palliative care funding mechanisms can compromise our shared aim in addressing need. 
This leads to the next policy failure which is around service planning and problematic due to care being split across levels of government.
Service planning relies on quality data and this is a key gap in palliative care. The sole Physician MBS item numbers map only a very small sample of service provision which really limits service planning, particularly in enabling patient choice to die at home.
This palliative medicine focus, while important, is limiting. It means that what is actually occurring at the community level in terms of GP-led palliative care is less likely to inform policy decisions. The undefined role of the general practitioner in palliative care across a range of settings is a contributing factor. While we are seeing more and more GPs with special clinical interests in palliative care meeting these needs in primary rather than secondary care, the system just doesn’t see them.
In the absence of item numbers, how can GP-led palliative care ever be fully measured? GPs play a critical role here. Chronic disease management and home visit item numbers are not sufficient in terms of planning for future demand or in capturing the complexity and non-clinical time involved in providing this care. The only available BEACH data shows that about 1 in 1,000 GP encounters in 2014-15 were palliative care-related, which equates to around 5 encounters per 1,000 population. This is most certainly an underestimate of the actual numbers given services delivered by GPs cannot be established from Medicare data.
Another key issue is that palliative care services have many individual providers both public and private. It is clear we need to get better at ensuring a more seamless service transition for the patient and family. Service integration prioritising multidisciplinary care at the local level relies on flexibility to facilitate the integration of funding streams. In rural areas, this can be particularly challenging even when there is a strong commitment by local service providers.
Service integration at the primary care level remains a key policy failing and much more effort is required to provide the necessary supports to enable a more integrated system.
General practice is the gateway for patients to the broader health system. We need new expanded funding measures specifically designed to enable service integration for palliative care in the community. Efficiencies can be found in community-based care, yet there is a reluctance to put the system supports in place to make it happen.
The recent $8.3 million announced in the Federal Budget will help boost the role that the PHNs have in coordinating end-of-life care. It is understood that the funding will support the provision of a facilitator which may help take the pressure off GP practices who are fulfilling much of this role already for their patients. But much more needs to be done in the area of facilitating greater access to GP-led palliative care services. Building local capacity to address increasing and future demand will require a significantly larger investment than we’ve seen to date.
Capturing broader perspectives
We know that demand for palliative care in Australia will grow. This, in turn, requires an expansion of home and community care in meeting patient preference. An important policy perspective needs to be captured from those receiving care and their caregivers. This will help us work through further how we can improve services to support dying at home.
A final additional focus therefore needs to be on the patient and caregiver if we are going to get this policy right.
A qualitative study of patient and family caregiver experiences of Hospice at Home care provides insights. It states that we need to focus on additional supports for older people and those living alone, recognised as high risk of being unable to receive this type of support. More targeted supports for older caregivers who are at a higher risk of caregiver burden are also required. The policy goal here has to be around promoting their quality of life with an emphasis on training for the full care team in the ethos of palliative care to ensure holistic care.
Where to now?
We know that GP-led community palliative care needs to be prioritised in policy. Yet there remains plenty of barriers limiting service expansion to facilitate this care from within the community and across settings.
Ensuring our system is more responsive to patient choice is of course what needs to drive all policy decisions. We know in this case that it is often a preference for care outside of the hospital setting. But when our system automatically preferences to tertiary care, it makes it harder to facilitate that care. This is unless of course you have well established and integrated service links and a significant local community commitment to make it work.
There’s a pattern emerging here and it’s about prioritising patient-centred healthcare in primary care. Access enabling choice, service planning and data capture, integration prioritising GP-led care and encompassing the patient and caregiver perspectives would bring us closer to a more responsive palliative care service system.
 AIHW. Web Report. Palliative care services in Australia. Last updated 24 May 2017. Available at: https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-in-general-practice
 Palliative Care Australia. National health statistics highlight inequitable access to palliative care. 24 May 2017. Available at: http://palliativecare.org.au/palliative-matters/national-health-statistics/
 Parliament of Victoria. Legislative Council Legal and Social Issues Committee. Inquiry into end of life choices Final Report. June 2016 PP No 174, Session 2014-16 (Document 1 of 2) ISBN 978 1 925458 38 1 (print version) 978 1 925458 39 8 (PDF version). Available at: https://www.parliament.vic.gov.au/lsic/article/2611
 Connor SR and Bermedo MCS. Global atlas of palliative care at the end of life (Worldwide palliative care alliance, World Health Organization), 2014, http://www.who.int/ nmh/Global_Atlas_of_Palliative_Care.pdf
 AIHW, op.cit. Profile of palliative care related hospitalisations.
 Groeneveld EI, Cassel JB, Bausewein C, et al. Funding models in palliative care: Lessons from international experience. McCaffrey N, Cassel JB, Coast J, eds. Palliative Medicine. 2017;31(4):296-305. doi:10.1177/0269216316689015.
 Australian Institute of Health and Welfare 2014. Palliative care services in Australia 2014. Cat. no. HWI 128. Canberra: AIHW.
 Palliative Care Australia. Budget offers new support to coordinate end-of-life care. 10 May 2017. Available at: http://palliativecare.org.au/palliative-matters/budget-phns/
 Jack B.A., Mitchell T.K., Cope L.C. & O'Brien M.R. (2016) Supporting older people with cancer and life-limiting conditions dying at home: a qualitative study of patient and family caregiver experiences of Hospice at Home care. Journal of Advanced Nursing 72(9), 2162–2172. doi: 10.1111/jan.12983
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.
[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.