Australia has more than enough GPs according to the latest report by the Grattan Institute, which has proposed a new model of general practice care – ‘teamlets.’
The report, A new Medicare: Strengthening general practice, highlighted that compared to the OECD average (0.9), Australia has more GPs relative to our population, with 1.2 GPs per 1,000 people – and the GP workforce should grow to keep up with the prevalence of chronic disease, with the number of GPs in training up by 77% over the past 10 years.
Lead author and health policy analyst, Mr Peter Breadon, the Grattan Institute’s program director for Health and Aged Care, and a former senior executive within the Victorian Department of Health, explained that the Federal Government lifted the number of domestic medical student places in the early 2000s, responding to concerns about medical workforce shortages.
“Between 2004 and 2016, the number of placements increased by more than 150%, from 1,300 to 3,300 per year,” Mr Breadon noted in the report.
“This has significant flow-on effects for GP supply. Between 2011 and 2016, the number of GPs in training increased by 80%, from 3,156 to 5,689, and the number of training places has remained at or above 5,600 since.
“The full benefit of this increase is yet to be felt because many of the graduates are still likely to be in training.”
That said, Mr Breadon also agreed that Medicare was in the grip of a mid-life crisis and the report highlighted that the complexity of GP work has grown immensely, yet the system – designed in 1984, when injuries and infections had the biggest impact on health – had not been updated in response, let alone trying to address the ‘gaping disparities’ in access to care, rates of disease, and life expectancy.
For example, the research showed that on average, Australians spent 13% of their lives in ill-health, more than people in most other countries.
“But a national decline of GPs does not seem to be behind current pressures,” the report said.
“Compared to the past, compared to other countries, and based on the number of services delivered and patient waiting times, Australia’s supply of GPs seems better, not worse.”
Mr Breadon explained that the system still overwhelmingly relied on GPs, who make up about 74% of the clinical staff in general practices, and suggested that a new funding model and diverse support teams for general practice could be the cure for Australia’s healthcare system.
“A lot of GP care could be done by others. While no measure is perfect, almost all the indicators we have suggest that deeper changes are needed than simply boosting GP supply further,” Mr Breadon said.
“For example, a leading estimate is that at least half of preventive care, and at least a quarter of chronic disease care can be safely delegated, with the remaining care performed by GPs and highly skilled clinicians who can work on their behalf.”
He pointed out that data from the American College of Physicians showed that nurse practitioners could provide care for at least 60% of patients, with multiple reviews confirming that the quality and results of NP care were at least as good as GPs,’ increased access to care, and reduced hospital referrals as well as overall costs – yet Australia has few NPs employed in general practice compared to other countries.
Similarly, a systematic review of 39 studies found that the level of care provided by physician assistants (PAs) had the same or better health outcomes, at the same or lower cost, as care provided by doctors alone.
More than 2,000 PAs have been employed in the UK and more than 120,000 in the US, yet Australia has just 30, and the report highlighted that even when support staff were in place, they were often under-utilised.
For example, the number of nurses working in general practices has grown significantly over the past few decades, but surveys revealed that three quarters of these nurses faced one or more barriers to using all their skills, with one quarter facing 6 to 10 barriers.
“In Australia, for every 10 GPs there are less than three nurses or other clinicians to support them,” Mr Breadon said.
“By comparison in England, for example, for every 10 GPs there are about 10 supporting clinicians, [and] in the US, nurse practitioners and physician assistants provide about 11% of all medical services delivered outside hospitals.”
A lack of support staff also prevented GPs from delegating tasks that did not require medical training.
“Only about 60-to-70% of surveyed Australian GPs have a nurse or an assistant to do tasks such as checks on chronic disease patients and health promotion. Yet in many other wealthy countries, almost 100% of GPs do,” Mr Breadon said.
The authors explained that ‘teamlets’ could form the core of a team-based multidisciplinary practice and were usually made up of a GP and at least one supporting clinician, who worked together daily. Each patient could be assigned to one teamlet, which would be responsible for their ongoing management.
“The supporting clinician or clinicians in the teamlet take on almost all of their GP’s administrative work, along with clinical tasks within their scope of practice, and documentation,” Mr Breadon noted in the report.
“They are also able to do work the GP often does not have time to do, such as preventive services, reviewing patient files before and between visits to see where patients are overdue for tests and check-ups, and regularly coaching patients on their self-management.”
The report stated that to realise these changes, general practice must first become a team sport, with many clinicians working under the leadership of a GP to provide more and better care.
“Second, Australia needs a new way to fund general practice. The current model is broken, actively discouraging team care, and rewarding speed, not need. Australia is one of the last wealthy countries to fund general practice this way,” the authors said.
“Third, general practices cannot keep working without clarity and support from government. They need a clear vision about where general practice is heading, with support and accountability for getting there.”
Specific recommendations included:
Expanding access by making general practice a team sport, with more clinicians using all their skills to share the load with GPs:
- Fund 1,000 new nurses, physiotherapists, mental health clinicians, pharmacists, and other allied health workers in the highest-need communities, to work within general practices alongside GPs and provide fee-free care
- Engage an independent commission to remove regulatory barriers that stop primary care workers from safely using all their skills, and to explain the new rules clearly
- Reduce waits and costs for specialist care, by contracting specialist advice for GPs to help them manage complex cases without referring patients to private specialists or hospital waiting lists
Change funding to support team-based chronic disease care, match funding with need, and close access gaps:
- Allow general practices to opt into a new funding model that fund more care for patients who need it, and supports GP leadership, team-based care, and ongoing relationships with patients
- In practices using this new model, expand access to the Medicare Benefits Schedule for nurse practitioners and physician assistants
- In rural areas where access to care is low or at risk, fund Primary Health Networks (PHNs) to support fragile practices or set up new services in partnership with states and local hospitals.
Set a clear direction and support improvement
- Show where we are going, with a long-term strategy for general practice that outlines what good care looks like, how it should be delivered, and how it fits into the broader system
- Give PHNs real powers to shape markets by rolling out the new funding model, the new workforce roles, and specialist support
- Measure what matters and encourage improvement with new data and reporting on access to care, quality of care, patient satisfaction, health outcomes, and who is being left behind
- Develop a strategy to improve data collection and use across the health system.
Avoid another dead-end trial by committing to a long-term plan:
- Commit to rolling out the new funding model over 10 years
- Give practices the help they need to adapt, including funding, expert advice, data analysis, and leadership training for GPs
- Invest in the capability of PHNs and the department of health to support and manage system performance.
“The Federal Government has set aside $250 million a year to respond,” the report concluded.
“That money can fund the recommendations in this report; repairing the foundation of our health system and creating a new Medicare that is ready for the decades ahead.”