Section 3: The model for high-performing patient care
Core features of high-quality general practice
Primary healthcare system reform around the world is currently guided by the ‘Quadruple aim of primary healthcare’.36
The quadruple aim
The quadruple aim (Figure 2) seeks to drive healthcare redesign in order to improve the health of the population, improve the patient experience of care, reduce healthcare costs and improve the work life of health providers.
Quadruple aim of primary healthcare
Achieving the four principles of the quadruple aim is needed to achieve a sustainable healthcare system. The Vision is based on the quadruple aim, but provides solutions based in general practice. As general practice is the most frequently accessed part of the healthcare system, it is logical to introduce reforms in this sector.
The Vision adapts the quadruple aim to general practice and aims to achieve its principles through:
- enhancing the patient experience – by encouraging patient-centred, coordinated care, where patients are empowered to have an active role in their healthcare by establishing a long-term therapeutic relationship with a regular GP and practice
- improving the health of the population – by addressing the quality of care for people with acute and chronic conditions, while also prioritising preventive care and ensuring that patients have access to evidence-based health services at their first point of contact with the healthcare system
- reducing per capita costs of healthcare – by recommending a shift in health funding to better support general practice and its focus on preventive care, and a move to providing care in the community and reducing reliance on expensive hospital services and tertiary care
- improving the work life of health providers – by ensuring that GPs are well recognised and supported to provide high-quality care to their patients through funding for the implementation of systems to address burnout and increase role satisfaction for the profession.
Improved satisfaction of GPs will also increase the attractiveness of general practice as a profession, helping to grow and sustain the future general practice workforce.
International evidence suggests that there are several identifiable features associated with high-performing primary care. These features are often grouped together to form a comprehensive model of care, most notably referred to as either:
- the ‘patient-centred medical home’23,37,38
- the ‘10 building blocks of high-performing primary care’.39
The combination of these features is considered as best practice primary care, and has heavily influenced the RACGP’s Vision. However, the Vision has been specifically developed by Australian GPs to take into account the local context and needs of Australian patients, and therefore does not mirror existing models entirely.
Our Vision is underpinned by six core features of high-performing general practice (Table 1). While GPs have the ultimate responsibility for their patients’ care, the general practice team plays a vital role in supporting the delivery of care. Therefore, supports need to be given to both GPs and the practice in which they work for these features to flourish.
Core features of high-performing general practice
Many GPs and general practices are providing care according to the principles of high-performing general practice, but Medicare is limited in supporting the full range of services required. Unless support for the sector is increased and better aligned to high-quality care, the healthcare system will become unsustainable and unable to meet the changing needs of the population.
Benefits of high-performing general practice
The benefits of supporting these features of high-performing general practice will be felt by patients, healthcare providers and governments, as outlined in Figure 3.
Benefits to patients, healthcare providers and government
Actioning the features of high-performing general practice
To ensure that GPs and their teams are able to continue delivering high-quality general practice care, a number of actions are required. The majority of practices already recognise these features and are trying to implement them with varying success due to limited support. Additional funding and support is essential for practices to routinely achieve these features.
Foster engaged leadership
High-performing practices have GP leaders who are engaged in and responsible for developing and leading the implementation of a practice’s measurable goals and objectives.40 As well as having a leadership role within the practice, GP leaders also advocate for patients and general practice within the broader healthcare system.
All actions required to achieve quality general practice require an engaged leadership team (including GPs and other members of the practice team) to identify priorities for improvement, facilitate and influence change processes, and measure goals and outcomes.40
Ensure all patients have access to timely, holistic and comprehensive quality healthcare
A well-resourced practice can provide patients with a comprehensive and holistic range of services that address their current and future physical and mental health needs in a timely manner.
Effective comprehensive care provided in the practice setting can reduce the need for more expensive care provided in hospitals or by other specialists.45 It is associated with slower growth in health expenditure, as well as better system quality, equity and efficiency.46
Facilitate all patients to form a relationship with a usual GP within a general practice
An ongoing relationship with a GP or practice allows for the provision of continuous and comprehensive care throughout all life stages.47
Patients should be encouraged to form an ongoing therapeutic relationship with their GP, which will lead to both having a holistic understanding of the patient’s needs. This is of benefit to the patient as well as the GP.48 The ideal patient–GP relationship is based on mutual respect and shared commitment to the patient’s health.
This relationship also enables practices to understand their patient population, enabling better-targeted and effective coordination of clinical resources to meet their patient’s needs.
Promote patient-centred care by supporting the involvement of patients in the planning and delivery of their care
Patient-centred care should be prioritised by recognising the patient as a partner in their healthcare. This partnership provides patients with increased understanding, confidence and awareness of decision-making regarding their healthcare needs and options for treatment.49
Patient-centred care extends beyond treating episodic illnesses, and may involve other individuals who support the patient, such as carers or family members.48
Enable the coordination and use of information within the practice team and the broader health system in a timely manner
In coordinating and using the information available to them, GPs and practices facilitate informational continuity of care. This involves using patient information held within the practice regarding past events and personal circumstances to ensure that current and future care is appropriate for the individual patient.23
As well as coordinating care within a practice, GPs and their teams have a crucial and trusted role in helping their patients navigate the wider private and public healthcare systems.
Improved collection and sharing of data will improve regional planning and provide practices with opportunities to reflect on their priorities and performance.
Support the multidisciplinary team
The Vision positions the GP at the centre of care provision, but acknowledges the importance and significant value of other members of a multidisciplinary team in providing care to patients.
A well-resourced, multidisciplinary GP-led team has the capacity to coordinate care and ensure that patient needs are met. This is particularly important for people with chronic and complex conditions.
Members of GP-led teams can vary significantly depending on community need, and often include nurses, allied health professionals and administrative staff.5
Prioritise disease prevention and early intervention activities
General practice is in a pivotal position to deliver preventive healthcare.
Preventive healthcare in general practice includes the prevention of illness, the early detection of specific disease, and the promotion and maintenance of health.50
Preventive care provided by GPs is critical in addressing the health disparities faced by disadvantaged and vulnerable population groups.50
Early access to health promotion and appropriate preventive care assists patients to stay more active in their community. This reduces the length of hospital stays and re-admission rates, and targets health resources to patients who will benefit most.
Support evidence-based patient care
Evidence-based patient care is a core standard for general practice in Australia.41,51 However, inadequate evidence relevant to primary healthcare can hinder GPs’ efforts to provide this care.
To facilitate patient access to safe, high-quality and evidence-based care from GPs, the primary healthcare system itself must be underpinned by rigorous evidence, for which primary healthcare research, and more specifically general practice research, is essential.52
Supporting general practice–specific research will facilitate patient access to contemporary, evidence-based medical services in the health setting they use most frequently.
Support education and comprehensive training of all health professionals
General practice provides a number of unique learning opportunities for all healthcare professionals. GPs have the skills and education to adapt to changing population needs. When given the appropriate training and support, they also have capacity to provide elements of care currently provided in a hospital setting.
Students of other health disciplines (both within and outside primary care) should be supported to undertake a placement in general practice to encourage a greater understanding of its value and role at the centre of the primary healthcare system. This will lead to better communication between the different sectors within the health system and, ultimately, improve patient outcomes.
Education and training are vital in meeting the quadruple aim of healthcare.
A highly trained and educated multidisciplinary team helps to ensure that all members can work to their maximum capacity, increasing efficiencies in providing care and improving clinician and staff role satisfaction.
Maintain a culture of data-enabled quality improvement and safety
The Vision encourages fostering a culture of quality improvement within practices, which will improve patient safety and care. GPs and practice teams should be encouraged and supported to reflect on their own performance and engage in quality improvement initiatives and activities. Quality improvement is an underlying feature of general practice care and is supported through practice accreditation and continuing professional development.
A culture of quality should support improvement to the provision of safe, high-quality, patient-centred care, based on the best knowledge and evidence. High-quality, evidence-based tools designed to improve the delivery of safe and high-performing care in general practice are needed. It is, and should remain, the role of the RACGP to design and set the standards for these tools.
Facilitate effective and efficient use of health resources
GPs and their teams contribute to the effective and efficient use of health resources by providing over 150 million patient services each year at a fraction of the cost of hospital services.53
GPs play a role in managing health costs by:
- providing accurate entries into a patient’s electronic health record to foster continuity throughout a patient’s healthcare journey
- enacting their role as healthcare stewards and ensuring that all referrals are appropriate and required
- using evidence to evaluate the need for appropriate medical tests, treatments and procedures, and avoid such tests, treatments and procedures where evidence shows that they provide no overall benefit
- providing opportunistic and systematic preventive services to stop or delay the onset of diseases and allow for early diagnosis of health conditions
- encouraging patient self-care
- avoiding complications of chronic diseases
- managing presentations that would otherwise result in an emergency department presentation (such as injuries, wound care or acute infections).