Donna M Southern, BSc (Hons), Grad Dip Epidemiology and Biostatistics, is Research Fellow, Department of General Practice and Public Health, The University ...
Integration from the Australian GP's perspective Donna M Southern, Natalie J Appleby, Doris Young Donna M Southern, BSc (Hons), Grad Dip Epidemiology and Biostatistics, is Research Fellow, Department of General Practice and Public Health, The University of Melbourne. Natalie J Appleby, BSSc, Grad Dip Program Evaluation, is Research Fellow, Program Evaluation Unit, Department of General Practice and Public Health, The University of Melbourne. Doris Young, MBBS, MD, FRACGP, is Professor of General Practice, Department of General Practice and Public Health, The University of Melbourne. OBJECTIVE To report on what general practitioners' perceptions are about their role in relation to activities that
support integration and what they are doing. METHOD General practitioner perceived integrative behaviour was measured using a survey containing 114
statements about, 'what constitutes a well integrated GP'. Four hundred and forty-eight GP, were randomly sampled from the Health Insurance Commission (HIC) Medicare billing database in 1996. A response rate of 47% was obtained, yielding 208 surveys for analysis. RESULTS General practitioners reported integrative activities such as being accessible to patients and working within a multidisciplinary team as currently occurring optimally. Not occurring optimally were: hospital and community involvement; participation in local projects; student education; and payment for working with others. Rural practitioners reported significantly more hospital and community involvement compared with metropolitan practitioners. Less than one-third of GPs reported that they were linked to other services by computer and used a computer for storage/communication of patient information. DISCUSSION There are many obstacles preventing integrative activities in daily general practice. Policy and attitudinal
changes as well as financial incentives are required to enable GPs to practise in an integrated manner. Infrastructure. support to encourage GP education, training and information technology are essential to improve GP integration. Many such initiatives are currently in progress, and will require future evaluation. Findings from this 1996 survey will provide some useful baseline information assisting with future evaluation studies.
Received 1 June 2000; accepted after revision 23 October 2000.
I
ntegration of primary health care services, including those provided by general practitioners, have received worldwide attention in health care reform.'-' In the UK, primary care groups have recently been established and in Australia, primary care partnerships have been encouraged in Victoria.' The General Practice Divisions Program has called for more involvement of GPs with other primary care service providers and the new Medical Benefits Schedule item
numbers grouped under 'enhanced primary care packages' were introduced in 1999 to reward those activities. General practitioner-hospital integration project officers were placed in state based organi. sations (SBO) to facilitate GP involvement with patient care in hospitals. The practice incentives program (PIP) has provided funding to GPs to improve their computer systems, teach medical students and provide after hours care to their patient population. Such ini-
:1.82 ~ Australian Family Physician Vot. 30, No. 2, February 2001
tiatives aim to better integrate general practice services with those of other health service providers and related organisations. Little Australian research has been directed at how Australian GPs conceptualise general practice integration or the style of practice that promotes integration. Despite the ongoing promotion and funding of strategies aiming to achieve a better integrated health care system, scant empirical data exists on the extent GPs
L-UpYllgJll 01 rUII I CAllC:~l~ WUH UIC VIIl;;UI4I
copyright owner and, except as permitted under the Copyright Act 1968, copying this copyright material is prohibited without the pennission of the owner or its exclusive licensee or agent or by way of a licence from Copyright Agency Limited. For information about such licences contact Copyright Agency Limited on (02) 93947600 (ph) or (02) 9394760t (fax)
Table 1. The 10 domains of the Integration Survey (1996)
Table 2. General characteristics of the survey respondents (n=208)
1. Holistic and flexible practice
To have an holistic view of patients, including their family, occupational, social,
cultural, spiritual, emotional and mental issues. To tailor health care to the
GP characteristics
individual, consider patients' financial circumstances and be flexible with time and facilities.
Gender
Male Females
75.9 24
Metropolitan
Male Female
52.4 17.7
Rural
Male Female
23.5 6.3
%
2. Care coordination
Appropriately sharing information with hospitals and other providers, and being involved in the discharge planning process. 3. Attitudes to teamwork
To be able to confidently identify problems that need referring elsewhere and be receptive to suggestions from other service providers, including other GPs. 4. Community health piannlng
To be a community leader and have a community planning role. To lend support and have links with community groups, committees and divisions of general practice,
Country of graduation Australia
74.5
Year of graduation
5. Political linkages
1970-1989
71.1
Have a role in local policy and planning with government and other services. Having awareness of changing government policy. 6. Knowledge and education
Have involvement in student education and ongoing medical self education. Explain
health issues to the patient to provide an understanding of what to expect when referring to other health professionals. Keep up to date concerning local health services, staff, and their policies such as referral and admission policies. 7. Time and funding
Issues concerning the GP payment system, Funding requirements to encourage integration, by covering payment for health promotion and disease prevention roles, as well as for co-ordination roles and working with other health providers. 8. Practice organisation
General practice organisation, such as having processes in place to communicate with other providers and a well organised practice (good receptionist support and clinical records). 9. Information technology
To use computers for the storage and appropriate communication of patient data. And electronic linkages to other services. 10. Personal domain/personal attributes
About the GPs health and mental status. Having opportunities to debrief, and be able to consider their own health and welfare.
are integrated with other health service providers and what the perceived barriers to achieving integration activities are. The term integration is often used loosely. Most definitions are at an organisation level or health system level~7 with little work defining what a well integrated GP is meant to do. In this study the definition of the term integration is that stipUlated by a national focus groups study,S,9
The aim of this study was to look at the capacity of the individual GP to carry out particular activities that are deemed to promote integrated general practice. As this national survey was conducted in 1996, the findings of this paper will provide a useful baseline for future studies to evaluate the changes that might have occurred as a result of recent financial incentives introduced by the Commonwealth Government."
Methods The survey was developed comprising 114 statements grouped into 10 domains Australian Family Physician Vol. 30. No. 2, February 2001 • 183
based on the themes identified by national focus groups in response to the question: 'Describe the role and circumstances of a GP who is well integrated into the health care system', where 'well integrated' in this context was defined as 'works well with'.···" The 10 domains of the survey are summarised in Table 1. The statements comprising the survey describe activities supporting integrated general practice and also form part of a GP's role within the wider community. General practitioners were required to indicate on a 5-point response scale, the degree to which they carry out these
activities. The statements comprising the domains were sorted randomly in the survey to mask the specific themes being explored. The survey also stated that there are no right or wrong answers and that the purpose of the survey was to determine the extent to which GPs were able to carry out the activities under their present practice conditions. General practitioners who did not respond to the original mailing received a further two reminder letters and a follow up telephone call. Returned surveys were excluded from analysis if they were less than 70% completed. The sample A random selection of 448 GPs listed on the Health Insurance Commission (HIC) Medicare billing database were mailed the survey. The sample was stratified by metropolitan, rural/remote and gender. On advice from our statistician, the sample was weighted 3:1 for metropolitan male GPs, as a low response rate was anticipated from this group. Eligibility was based on a minimum of 1500 Medicare services in the most recent 12 months.
A summary comparison between our drawn sample of GPs, its sample frame and the GP population from which it was drawn was provided by the HIe. There was no difference in relative distribution
of the total population of GPs with 1500 Medicare services and the sampling frames. The drawn sample of GPs also compared well with the sampling frame (p;0.99, Chi-square 0.621, df;7).
Results Response rates and demographics A 47% (n;208) return rate of satisfactorily completed surveys (ie. at least 70% complete) was achieved. An additional 10% of surveys were returned either less than 70% complete, or blank. The nomesponders (40%) did not differ in profile (gender and ruraVmetropolitan location) from the surveyed population. The characteristics of respondents are reported in Table 2. Female respondents are underrepresented as a result of oversampling of males by 3:1 and Victorian and NSW GPs represent the majority of the sample. Work hours and location General practitioners were asked about the number of hours per week they work in private general practice, hospitals, community health centres and extended hours clinics, as position type was hypothesised to have some bearing on capacity to perform activities that support integrated practice. All respondents reported spending most time working in private general practice. Of note, female respondents reported working 16 hours less than males (p
