Appetite for change among younger GPs

YOUNGER GPs are recognising that a multidisciplinary team environment allows everyone to operate at their best, and there is a generational shift towards reform in primary care, according to an Australian expert.

Dr Jean-Frederic Levesque, chief executive of the NSW Agency for Clinical Innovation, told MJA InSight that younger clinicians found it hard to return to solo practice once they had experienced a team environment.

“Younger doctors are increasingly recognising that a multidisciplinary team environment allows everyone to work at the top of their practice,” he said. “Evaluations to date have suggested that once clinicians have worked in that environment, it’s difficult for them to return to medical doctors-only or solo practices because they can see they have lost the advantage of working with people from different professions with different skills.”

Dr Levesque was commenting after research was published in Family Practice, identifying four dimensions that underpinned interprofessional teamwork in primary care: structural (organisational requirements for a team), operational (processes to conduct activities, such as guidelines, meetings and collaboration), relational (leadership and team relationships), and functional (roles and responsibilities and team objectives).

Dr Levesque, lead author of this research, said that interprofessional teamwork was increasingly needed to reflect the more complex care needs of patients.

“Patients have changed over the past few decades. Increasingly, people require more long term follow-up for chronic diseases and disabilities, and often the evidence-based treatments require provision of care from various professionals.”

He said that teams that did not function well together created duplication of tests and procedures, communication problems and issues with continuity of care.

“Increasingly, teamwork is the key to making sure that patients get good, integrated, coordinated care for their chronic disease,” he said.

Dr Levesque said that central to all models that had effectively implemented teamwork was a structural dimension, describing arrangements such as legal status, team composition, location, technological support and funding.

“It’s important to have a clear plan and really give existence to the team by saying ‘this is the series of professionals that are part of the team’. This really starts the conversation: how do we evolve the other dimensions, and start to have tools to enable us to operate together as a team?”

He said that the studies suggested that the structural element was the first stage in the implementation of a framework, but effort was required on all four dimensions to be truly effective.

In a second article by Australian-led researchers in the same issue of Family Practice, an international consortium analysed data from studies into primary care models in Australia, Canada and the US to identify the factors essential to successful team-based primary care environments.

The researchers reported that traditional practice ownership and funding models had been a barrier to creating team-based environments.

“The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implementing team-oriented primary care,” the researchers wrote.

“Policy makers facilitating team-oriented [primary care] may need to decide as to whether they have the energy to dismantle fee-for-service payment structures and reorient the long-lasting cultural dominance of the medical profession.”

Lead author Professor Grant Russell, professor of General Practice Research at Monash University, said that there had been a shift in primary care from small, physician-owned practices to much larger, complex practices employing nurses and, sometimes, allied health care professionals.

“There is emerging evidence in primary care that improved teamwork is associated with improved clinical outcomes and patient safety,” Professor Russell told MJA InSight.

“But [interprofessional] teamwork has been difficult [to achieve]. While there is some evidence that interprofessional education can improve teamwork and, in turn, a range of clinical outcomes, in the primary care setting, such interventions have generated only modest impact on professional practice and health outcomes.”

The researchers identified seven levers that influenced the implementation of primary care teams: clinical payment methods, clinical work distribution within practices (extent of direct physician involvement in service delivery), practice governance (extent of physician ownership), external accountability and regulation, community and medical neighbourhood connections, the role of the professional organisations, and supportive external resources.

Professor Russell said that these levers provided some guidance in the types of reform necessary for the implementation of team-oriented care.

“If you are intending team-oriented care, you need to explore non-fee-for-service funding mechanisms, be aware of the implications of physician ownership and control of primary care practices, get professional associations on-side, and provide external support to practices that are going through the hard work of primary care reform,” he said.

Professor Russell said that the new Health Care Homes model, for which trials began on 2 October 2017, featured some incentives for team-based care – such as some capitation payments for at-risk patients – but many of the traditional structures remained.

He said that Health Care Homes would be physician-owned, and it was likely that clinical work distribution and direct physician involvement in care would feature in these models.

Professor Russell said that the Family Practice study also highlighted the importance of having the support of professional organisations in establishing team-based primary care models.

“If you have a Health Care Homes model – and we saw this in Australia with the GP Super Clinics Program – where the professional associations are not particularly on board, that makes it harder to transition [to a team-oriented model].”

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