Building GP capacity in times of disaster

DISASTERS in Australia in recent years have all, inevitably, involved responses from GPs. They live and work in the communities that are struck and manage 95% of the community’s health care, but little of their response is reported or documented.

Record-breaking temperatures on top of a long drought left large tracts of Australia in tinderbox condition, and by early 2020, bushfires were raging across almost every state and territory.

As evacuation centres opened and closed, people in small rural Australian towns became more isolated — even in small communities used to hardship and self-sufficiency. Small rural towns have been brought together in evacuation centres by these fires. Many evacuees had experience of previous bushfires and evacuations, but in Australia’s Black Summer of 2020, this sustained assault on human and animal lives, on over 10.7 million hectares of local forests and environment, was unprecedented in most local people’s lifetimes.

Disasters are about people and environment. It is the experience of people and communities during one of the most distressing and frightening moments of their lives that helps shape their recovery. The effects on health are well documented in the literature; they start from the moment of threat and continue in the days, decades and even generations that follow.

Disasters affect human lives across many dimensions: loss of life (human and animal), loss of health (physical and mental), loss of livelihood and home, and loss of a sense of safety and trust in authorities. There is also loss of the things that define us – history and memories, community, connection. Loss is not just absence but also comes with change, as we lose what might have been. The trajectories of lives are transformed, careers are diverted, education rerouted. Disasters have been described as a social determinant of health. Public, population and preventive health come to the fore, areas to address that are very familiar to local GPs.

The communities affected by fires this summer in Australia are as diverse as the threats they have encountered – coastal, mountain, farmland; smoke, ember attack and fire. The way each community has endured and responded to this disaster will be shaped by their previous experiences, and by the people, places and services that form their community. The scale of this Black Summer’s fire disaster means many communities are relying on external aid to recover. This support must be responsive to the unique needs of each community and acknowledge the diversity of threat, impact, experience and capacity of each individual community. Supporting agencies need to consider and consult the community in planning, response and recovery.

This is where the experiences of our community health providers are critical. GPs living and working in the community are a keystone of that community’s wellbeing. The community itself knows the value of its own GPs, who have been with them through health, illness, joy and trauma.

All disasters have unpredictable characteristics. The Black Summer of 2019–2020 has already taught us new lessons and reiterated old lessons not yet acted on. A community offered warm applause to the local GP who volunteers to be on call for the impending catastrophe. The hospital and emergency services have few mechanisms for using GPs in their approved protocols, whereas the local evacuation centres invited them in, saying “We know you, and we trust you implicitly, and we need you”. An online community of peers took action to clear a path to health resources within hours. Across district and state borders, a virtual community of colleagues demonstrated how GPs can pull together to support each other. These are not hypotheticals – these words describe events on the South Coast of New South Wales in January 2020.

Cobargo GP Dr Jeffrey Lee was a case in point, setting up his practice in a motorhome after his surgery burnt to the ground.

As the 2020 emergency unfolded, the majority of the response has been GPs working in their practices managing the ebb and flow of need. There was an acute flood of locals into the waiting room in the first days, finding a safe place to gather and express their distress. Health care triage of undifferentiated conditions as well as management of exacerbations of chronic conditions, minor trauma, replacement of routine medications, care of the elderly, care of pregnant women and of newborns, and psychological distress were the predominant needs.

Consider also the drop in practice income in an evacuated region, while staff still need wages to sustain their own lives. GPs now face the awful choice during the rebuilding of whether their practice can afford to bulk bill, or whether their patients can afford to pay. In previous disasters, much of this response has involved GPs going above and beyond – emotionally, financially, personally and continuing this for months, perhaps years.

The issue is there is little understanding of how GPs contribute to disaster health care “beyond prescriptions”, or how to best support them in the response and, perhaps most crucially, how to communicate and involve them as one group across planning, response and recovery.

There is little record, particularly in the scholarly literature, or in government reports, of the contribution of GPs during these events. In examining the literature one could be forgiven for concluding that GPs were not involved. However, they are intimately involved as trusted local community health professionals often stepping up to a self-defined role to aid their community during its worst adversity. GPs have consistently shown strength and courage in these events, sometimes suffering personal consequences as a result.

What are the ways forward?

Now – perhaps for the first time – there is both appetite and opportunity to build a strong, mature, nationally consistent and locally responsive model where individual elements of the health system – including GPs – are enabled to contribute to the whole, for the greater good. GPs are advocating for their communities and for themselves as essential to disaster health care. They are clearly describing their value in health care and it is being heard. This is creating an opportunity for change but it needs to be focused on building on what exists and on long term sustainability in addition to addressing immediate needs.

The current emerging response system for GPs in disasters is through their Primary Health Networks (PHNs) linked into the Local Health Districts (LHDs) to the rest of the emergency response.

The Nepean Blue Mountains PHN, motivated by the 2013 Blue Mountain bushfires, has been quick to establish their systems. Lessons learned have been used to create a living document on the emergency role of GPs outlining how they connect to the system and defining responsibilities, roles and resources for evacuation centres. An evacuation pack is available with tabards and equipment.

GPs are positioned in evacuation centres in a role under the PHN. Nepean Blue Mountain GP volunteers have been sought in advance through an expression of interest. They have been given access to Major Incident Medical Management Support training that outlines disaster systems and disaster triage. Disaster mental health sessions from the Red Cross have been delivered in the area in 2018.

When fires arrived again in the Nepean Blue Mountains in November 2019, the PHN and LHD communicated in regular meetings. Updates on the situation were then sent out to all local GPs, with extra preparedness about their role for those on standby to attend evacuation centres. GP liaison officers contacted practices in more affected areas directly and assessed capacity to take extra patients. The website has been updating the situation and providing links to resources. Resources including HealthPathways on disasters were established in the lead up to what was to be a bad fire season.

Other PHNs are contributing their own experiences, planning and resources. The expectation is that as all PHNs refine their preparedness and links with their local LHDs, the linkage of GPs into the systems will improve.

How to use this opportunity for change

We see three priorities at this time:

1. The first is a commitment from government and GP organisations to sustain the current level of support and prioritisation being shown towards GPs in affected communities regardless of the wane in focus that will inevitably be seen in the months to follow. GPs need to be central coordinators of community health care during disasters. They are in their communities for the long term, and disaster effects are long term.
2. The second is an urgency in integrating GPs into disaster systems. This requires embedding them in local, state and federal disaster plans and policies, including GPs or representatives in planning meetings and exercises through the PHNs, and in clearly defining their roles in all phases of disaster management. This also requires funding for establishment and sustainment of the GP capability.
3. The third priority is inclusion of disaster medicine in the medical curriculum. There is a duty of care to protect the next group of GPs who will inevitably face these horrific events in the future. If we can provide preparedness through disaster medicine awareness we can help build capacity and resilience to sustain the next generation of GPs through each crisis, and on through the changed environment in the decades to come.

We see these three priorities as the mechanism to strengthen and support a crucial element of disaster health care – general practice (and primary care more broadly) – and build capacity among GPs and create a more disaster-resilient health care system. It is not solely the responsibility of the government and training and medical representative bodies to make this happen. Every Australian GP has a part to play in this preparedness.

Academic teaching GPs can educate and prepare medical students and GP registrars on their roles in disaster health care, the health conditions they will need to be able to manage, and, crucially, how to monitor and maintain their own wellbeing if immersed in such an event.

Academic research GPs can contribute to the research and scholarly articles demonstrating the clear burden of care that GPs are managing. This will provide evidence to support policy makers so the value of GPs can be recognised along with the benefit of inclusion in disaster plans.

GP principals and supervisors can lead by example, guiding and mentoring students and registrars through the challenges and barriers to community and rural practice, showing them the joys and rewards, so they emerge as the next generation of skilled, wise and resourceful community GPs. They will be ready and able to prepare, respond and recover with their community.

GPs can attend planning meetings and disaster exercises (through PHNs) with other disaster responders to develop relationships and trust and to provide an understanding of GPs capacities and what they need to support them.

GPs with special expertise in disaster management, eHealth, mental health, paediatrics, aged care, disability, business, addiction and abuse can help develop one-page resources, ready in advance to send out to GPs, targeted at helping disaster-affected patients in their specialist areas.

GP locums can assist with respite for GPs in affected communities. GP practices can buddy with affected practices to provide support.

GPs leaders can advocate and deliver messages to government on the urgency to integrate GPs into existing disaster systems and on how to build resilience and capacity in the GP and primary care workforce.

All GPs, rural and urban need to be disaster-prepared in the context of their own community and hazard risks, and understand the crucial value of their contribution in disasters.

In Australia, GPs are coming together to unite and advocate for their patients and communities, and for their profession and themselves. At an international level, the World Health Organization is calling for primary care “to have well-defined and recognized roles … linked with secondary and tertiary [health] care systems … [with] primary care leaders … included in the planning and coordination mechanisms for health emergency management at all levels”. Until GPs are integrated into disaster systems, the health of Australians affected by disasters is compromised, including that of local GPs.

Dr Penelope Burns is a GP undertaking a PhD at the Australian National University on the role of GPs in disaster health care and building capacity of existing disaster systems.

Dr Kate Manderson is a GP from Shoalhaven in NSW. She successfully balances practice ownership, governance roles, military work and parenting using a careful mix of sleep deprivation and caffeine.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.