Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please can you describe how the average length of a patient consultation has varied over time in Australia?
Well it hasn’t varied at all over the last 15 years, which I find pretty amazing because we’ve been through a lot of changes in general practice. Yet, the average length of consultation, as measured from a start to finish time, in a sample of 40,000 consultations in Australia in a year, shows that the average is 15 minutes and the median is 13 minutes.
I am a bit surprised about this, but we know this from the BEACH program (Bettering the Evaluation of Care and Health). We conducted this study, and have been doing since 1998, with 100,000 consultations a year from ever changing random samples of 1,000 GPs a year, so we know their start and finish times and we can say the average is exactly 15 minutes.
Why do you think the average length of a patient consultation has not changed?
Many GPs run on appointment times in Australia and they can be 10 minutes or 15 minutes, depending on the practice. But, I think that more do a 15 minute appointment system and therefore they just have to run to that if they are going to stay on time.
If you look at the distribution of consultation lengths over time, there is much more variance now than there was 14 years ago, because the GPs are spending more time with chronic disease consultations and perhaps less time with the acute issues. So the distribution it is broader than it was, but the average is still 15 minutes.
Why do you think Australians are seeing their GPs more often than they were a decade ago?
I think that has a lot to do with policy. Remember that Australia has only had a national medical insurance system paid through our taxes since the early 1970’s. That may seem a long time to some people, but it is not long compared with many other countries.
By 1998, we had got used to having coverage for most of our GP consultations, but many of the GPs were charging additional fees to the amount paid under the insurance schemes. Policy tried to change that, our Australian Government brought in encouragements and incentives for the GPs to just charge what the insurance paid. So, the attendance rate gradually went up and then General Practice became very costly to the GPs, so they started charging additional fees and people stopped going again.
In 2004-2007 the attendance rate dropped right off and then the Government brought in a new financial incentive for the GPs to just charge the insurance amount. A lot of GPs moved to that and suddenly since 2007 it is essentially free to visit the GP and I think that has just increased attendance rates.
Other things have also happened in policy. The Government has changed financial incentives to encourage the GPs to do more chronic disease management, particularly diabetes management and depression. There are particular aspects emphasized by the Government—the GPs have to do a certain number of visits per year to get The diabetes incentive, and ensure completion of specified tasks to get either the diabetes or depression incentives. So unsurprisingly, there was an increase in the visits for depression and for diabetes.
It is not necessarily a bad thing and there is a slight decrease in the number of visits for acute illnesses, (for example) short term gastroenteritis and the common cold). So the whole of the workforce is moving towards more chronic disease management and less acute illness management
Why do you think GPs are now fitting more into their patient consultations?
That has a lot to do with this chronic disease management issue. And that’s combined with the introduction of practice nurses with incentives for GPs to have practice nurses assist either during, or after the consultation. So, if they’re doing chronic disease management, they can now ask the practice nurse to assess the patient, do their height and weight, assess their current status, get the current problems, and really get a full picture of the patient – even if the GP has been seeing them for years.
So, a lot of that work is being picked up by the practice nurse and if that’s being done you can fit into the consultation the updating of the diabetic status, the hypertension, the hyperlipidemia more than you could before when you had all that paperwork. And also the nurses are doing a lot of the procedural work such as the vaccinations and immunizations, wound dressings and so forth because those were specific practice nurse activities paid for by our Australian Government.
So, if GPs do not have to do those things, they can cover more issues at the consultations than they could before.
What impact do you think these trends have had on general practice?
It is changing dramatically, are older – our average GP age is 52. Many of them are heading for retirement. Now polices have been introduced to provide more training places for young people but training takes time, and meantime General Practice is stressed because of workforce issues.
It is not so much that we don’t have enough GPs but that they are maldistributed. Not like in England where you have workforce distribution organised. Once our GPs are fully qualified they can join a practice that is already established, or they can establish a new one anywhere they like.
Most GPs don’t really want to live in the outer regions of Australia, the extremely rural areas, so we have an extreme maldistribution. This is putting a lot of stress on the rural GPs, who only make up about 30% of all GPs, and are distributed across a very large geographic area. Many rural GPs have closed their books—they can’t take any more patients. This means some patients in areas of workforce shortage may wait 4-6 weeks perhaps for an appointment.
In contrast, in the major cities, such as Sydney, Melbourne, Perth, etc, the GPs are just very busy. It seems to me that the metropolitan population will use the available GPs to capacity because there is no cost in most areas attached to their visit.
In addition to being stressed, I think the older GPs are having trouble adapting to the introduction of an increasing number of policy initiatives for which there is a lot of paperwork for the GP. There are constant complaints about the amount of red tape associated with all these Government incentives .
I’ve been in General Practice research for 32 years and the BEACH program is the culmination of about twenty years of preliminary methodological development and testing. BEACH ensures that we have up-top-date information about the GP clinical activity in Australia. I often see very specific policies announced, that are aiming to change the behaviour of GPS. But when we look at the data, the change has already started and often you don’t see any additional change as a result of the policy. I often wonder whether committees are brought together to discuss an issue that have been identified because the GPs are already thinking and talking about them and are already acting upon the issue —that is why it has come to the attention of the committee.
So the committee brings in incentives, but the GPs have already done it, so the incentives make no difference. I think that often the GPs are well ahead of the policy. Of course, this is not always the case—there are some issues of quality of care in every country but in general, our GPs’ quality of care is measurably very good.
Do you think these trends will continue?
Yes. I’m hoping that the ageing GP population trend will decrease as all these new graduates are coming through. But of course the young ones are very different to the older ones, they don’t do home visits, they don’t do nursing home visits – I don’t know quite how we are going to solve that one. But yes we will move to a far more collaborative approach in primary care. Physiotherapists are starting to be employed, or have a collaboration in general practices on site.
There are some clinics that have been set up by our Australian Government at very large expense, that will provide broad coverage with the major specialities, and allied health professionals available on site. I think that as in most countries, with the ageing population of Australia, this will be required more and more.
We do a lot of research into multi-morbidity in our GP attending population. The current system in Australia requires those with multimorbidity to visit multiple sites to see multiple specialists for our multiple problems. Something in the system has to change and the GP will be the core of that group, coordinating that care. But I can’t see it changing very quickly.
How do you think general practice in Australia can be improved?
Well picking up on the multiple-morbidities, we do have a system that is body based, as many countries do. For example, you go to the cardiologist for heart issues, you go to the endocrinologist for diabetes and so forth. With an ageing population and people living far longer, we are going to need to work out how to put these services together. The super clinics are a start, but they have been very costly and so far not very successful, so I think it is going to take a lot of time.
General practice itself, I think, will mature to the inclusion of more allied health professionals on site in their practice and the younger ones coming up I think will accept that more than the older ones, because it is very different from the old General Practice that I knew 30 years ago where most of the GPs were solo. Now most of the GPs work in practices and the practices are getting bigger.
The GPs are working fewer hours and in a maldistributed profession this is a problem. They are getting more freedom when they join the larger practices to take more time off and to not work 11 sessions of face to face patient care a week. That might be helpful to the GPs, they will be healthier if they get a bit of time off, but in the maldistributed areas where they don’t have enough GPs, the GPS looking for better work/life balance and looking to work fewer hours are not going to improve patient access to the GPs.
So I think it is going to take a lot of time but I think the major improvement will be a better collaborative approach with GPs being a central control point and the specialists and allied health professionals working together with the GP to provide more holistic care than we have at the moment.
How do you think GP consultations in Australia compare to other countries in the world?
Well the last study we did comparing consultation lengths for example was in 2002, so that was 10 years ago. We found that the consultations here were of a similar length to those of New Zealand for example but longer than those in the UK. We didn’t publish this research for a lot of reasons, but of course the UK has a completely different system which allows far greater access than the Australian appointment system—we run with no patient lists in Australia, people being free to visit multiple GPs and multiple practices at any time.
I think that the complexity is growing in every country in the world. Certainly in the western world we have this ageing population with the GPs becoming the central point of planning the care of the patient as a whole. I know that in the UK, the GPs have taken that responsibility more and more in the last decade. I think that will happen in Australia and I think it will happen more and more in other countries. The US is very keen on the “medical home” . They are trying to encourage people to ‘belong’ to a specific practice which ensures that the work of all of the specialities and allied health professionals can be brought together.
But overall, I think that Australian GP consultations compare very well for complexity, length and in all our quality measures, to other countries in the world.
Where can readers find more information?
If you want more information the BEACH program provides reports on what’s happening in general practice every year and those are freely available on the website: http://sydney.edu.au/medicine/fmrc/
About Associate Professor Helena Britt
Professor Helena Britt is Director of the Family Medicine Research Centre, School of Public Health, University of Sydney. She is chief investigator of the BEACH (Bettering the Evaluation and Care of Health) program, a continuous national Australian study of GP clinical activity—now in its 15th year.
Originally a psychologist, Helena gained her Doctorate in general practice after time with her young children. She has worked in general practice research and development for more than 30 years, and is a member of the Executive of the International Classification Committee of Wonca (the World Organization of Family Doctors).
In the last 25 years Dr Britt has authored about 200 journal articles and 38 books on general practice activity, adverse patient events, multimorbidity, primary care terminologies and classification, impact of policy changes on general practice, and methodological development.
Her mantra is ‘bad data are worse than no data, because it leads you to the wrong conclusion.’