CURRENT PROGRAMS AND PROJECTS

After -Hours Service

The FRDGP working in partnership with neighbouring Divisions of General Practice, has established a collaborative structure for GP members access to an effective after hours system based on a needs analysis and feasibility study.

The project will ultimately improve consumer access to after hours GP services in the south metropolitan area of Perth. Independent GP After-Hours Services, collectives of local GPs are currently operating from Fremantle Kaleeya Hospital and St. John of God Healthcare, Murdoch. The FRDGP, with other metropolitan divisions, is participating in a Commonwealth program evaluating the Health Call Centre working with GP After-Hours Centres.

Aged Care Coordination Proposal

Aged Care was an area of priority for the FRDGP in the previous block grant period via the work undertaken by the Doorway Project. The project has provided the foundation for the development of proposal for a Coordinated Care Trial in Aged Care. Although negotiations with DHAC are still in the early stages, it is likely that the trail will be a collaborative program with the Canning Division of General Practice.

Cardiac Rehabilitation

Cardiovascular disease (CVD) remains as the leading cause of death in Australia. The economic burden to the community is immense. CVD is well recognised as a national health priority area for Australia. The Healthy Hearts Lifestyle Management Program was initiated in September 1997 following the results of community needs analysis conducted by the FRDGP in 1994. Results indicated that 69% of respondents had at least one CVD risk factor, 29% has two risk factors and 6% had at least three risk factors. This coupled with approximately 1000 CVD related procedures and/or admissions to Fremantle Hospital over the previous two years indicated a need for a

comprehensive community based service. The initial program recruited 149 patients and was highly successful in demonstrating risk factor modification. The proposed plan for the next 2 years should see improved awareness of CVD guidelines and risk factor management among GPs and members of the community.

GP Support and Communication Program

A discrete program relating to GP support and communication has been highlighted as a priority for the Fremantle Regional Division of General Practice (FRDGP) in the current strategic plan. Activities and important strategic initiatives relating to support services for GPs and their surgeries occur in a variety of FRDGP Programs. The current approach represents a more flexible response to the changing environment of general practice.

Recent initiatives relating to Accreditation, Amalgamation, Practice Incentives Program and Enhanced Primary Care Items has prompted the Division to appoint a Director of GP Support Services. In addition, information provided by the FRDGP's recent GP Needs Analysis suggests that the Division may wish to more clearly demonstrate achievements in providing relevant and useful services to GPs in their practice.

Information Management and Information Technology

The GP Strategy Review identified the use of information management and technology (IM/IT) as a crucial factor for ensuring general practice maintains the high quality of care provided to patients. The use of clinical software offers benefits to both GP and patient, while the interchange of data between general practice and other health organisations facilitates continuous improvement and efficiency in general practice. The effective use of information technology will facilitate the participation of general practice in health service reforms. As a consequence, IM/IT has been identified as a core part of the Commonwealth Government's Practice Incentive Payment Program (PIP). The IM/IT payment structure is intended to support practices in providing better care by use of modern IM/IT including electronic prescribing and the interchange of electronic data.

The FRDGP has made the commitment to support GPs with their IM/IT needs especially in relation to technical support and training.

Indian Ocean Territories Health Services

Situated in the Indian Ocean 2 300 kilometres northwest of Perth in the Indian Ocean, Christmas Island is 135 square kilometres, 63% of which is National park. Two GPs currently practice on the island. Also in the Indian Ocean, the Cocos group is an isolated cluster of islands 2,750 kilometres northwest of Perth and one general practitioner is currently employed on the islands.

The Director of Nursing who resides on Christmas Island oversees health services on all islands. The Commonwealth Department of Transport and Regional Services administers the Islands and Fremantle Division of General Practice has responsibility for providing support to the general practitioners.

Most services to the GPs are catered for through current Division programs such as GP Support and Communication, Information Management/Information Technology and Education and Professional Development. However, additional support is required for the GPs to overcome a sense of isolation from peers and colleagues.

Special consideration is given to the importance of communication with these GPs and facilitating for them the services offered to other GP members of the Division.

Continuing Medical Education - GP Education and Professional Development

A core function of the Fremantle Division of General Practice is to provide quality education and resources to GPs to improve knowledge, skills and practice in areas of need. The Division will provide and support a range of education and audit activities, primarily in line with the other program areas with occasional CME events provided in other unmet areas of need. The Division will also assist GPs in developing individual education and professional development programs.

The Quality Assurance Cycle, taking into account evidence based medicine and adult learning principles, will inform the development, implementation and evaluation of activities in this program. The aim is to ensure that continuing medical education be linked to the workplace, planned to meet GPs' needs, and based on selfassessment and peer review.

Work in this area will often involve collaboration with other Divisions, the Royal Australian College of General Practitioners, hospitals, pharmaceutical companies and other education providers in order to develop a coordinated approach and reduce duplication of effort.

Community Liaison Officer

The Fremantle Regional Division of General Practice Consumer Reference Group (CRG) has received Outcomes Based Funding (OBF) for the last two years. This funding provided the opportunity to employ a Community Liaison Officer to provide organisational and administrative support to the CRG. The Fremantle Division (FRDGP) receives

consumer input into the projects it undertakes and into the development of Strategic and Business plans. This process assists in ensuring that there is an improvement in GP services and health outcomes in the community.

Consumers and general practitioners are increasingly being recognised as partners in achieving health, both at the individual and community level. This partnership needs to be incorporated at a Divisional level by ensuring that the CRG is involved in day to day planning, implementation, management and evaluation.

The CRG has identified numerous strategies that have assisted the Division in maintaining a consumer focus in the services it provides as well as the services provided by General Practitioners.

Fremantle Hospital and Health Services

The over riding goal of the Fremantle Hospital and Health Service (FHHS) GP Liaison program is to facilitate communication between GPs and the Hospital, to enhance continuity of care for patients and improve access to and utilisation of hospital services.

GPs play an important role in the continuum of care, therefore, initiatives to improve communication between the Hospital and GPs can enhance patient outcomes. Admission and discharge communication methods and processes are a prime focus.

The presence of Liaison GPs within the hospital enables them to fulfill an advocacy role representing patients, the FHHS, and GPs.

Immunisation Program

Dedicated Commonwealth funding to Divisions of General Practice supports recognition of the importance of immunisation for children and adults as a National health issue. Divisions play a critical role in providing support and networking opportunities for their GP members who play a central role in preventive health care.

General practitioners in WA provide at least 79% of childhood immunisation. The strategies of the Immunisation Program aim to improve immunisation coverage, promote quality of service, improve the quality of data forwarded from the Australian Childhood Immunisation Register (ACIR), and develop initiatives which target children who have historically been difficult to immunise.

Increased integration of general practice with other immunisation services will improve continuity of care and access to services. Greater GP knowledge of and compliance with cold chain management recommendations and the increased use of electronic patient identification and recall systems, can improve quality of service and immunisation rates.

Quality Use of Medicines

Polypharmacy, the prescribing of multiple drugs for a patient, is most common in older adults because they tend to have more illnesses for which medications are prescribed. It causes significant morbidity and mortality in the aged and accounts for 10-20% of all geriatric admissions to acute care hospitals, thus straining hospital budgets and consuming valuable health care resources. In Australia, at least one-third of health care expenditure is directed to the elderly.

Polypharmacy is encountered daily by General Practitioners (GPs) through their close association with the care of the elderly. In addition, the incidence of adverse drug reactions (ADR) and drug-drug interactions increases exponentially with age and the number of drugs taken, while physiological changes occurring as part of the natural aging process also contribute to adverse drug reactions and toxicity's. When three drugs are prescribed the potential for an ADR is 30%; for five drugs the potential increases to 50%; and for eight drugs or more the potential for an ADR can be as high as 100%.

Kwong demonstrated that non-interfering feedback and a peer contact support system significantly reduced unnecessary medications by 22.8% in an Australian nursing home study. In addition, locally adapted clinical practice guidelines have been shown to bridge the gap between medical research and clinical practice and are actively adopted and implemented by GPs.

The current program represents the first national collaboration of general practice, government, academia, industry and consumers established to deliver a program aimed at promoting quality use of medicines in general practice.

The collaboration DiNCQUM GP (pronounced DINKUM GP) comprises; Central Coast NSW Division of General Practice; Central Sydney Division of General Practice; Fremantle Regional Division of General Practice (WA); Osborne Park Division of General Practice (WA); Health Insurance Commission; Commonwealth Department of Health and Family Services, NSW Medicines Information Centre; Department of Health and Family Services and the Pharmaceutical Alliance.

A CME accredited education program will be used by Divisions to upskill a wider group of GPs in better prescribing practices for the elderly. The education program will aim to provide GPs with an improved understanding of the factors that put the elderly at increased risk for adverse drug reactions, the physiological changes of aging that may produce an altered pharmacological response, and the issues associated with adherence to drug therapy. The program will target common groups of drugs used by elderly particularly cardiovascular and psychotropic drugs.

Building on the polypharmacy skills and knowledge outlined in the CME education program an audit program involving medication reviews will be used as key education/intervention strategy for groups of 20 GPs per Division.

Women's Health

Fremantle Division of General Practice (FRDGP) has established a good record in promoting women's cancer screening in the region over the past three years. During that time it has become apparent that it is possible to maintain an increase in Pap smear and mammography screening uptake while broadening the focus of preventive care for women aged fifty and over.

Cancer incidence in WA women is increasing. The incidence of lung cancer has increased by 5.4% (agestandardised) in WA women since 1988. In WA the estimated lifetime risk of developing melanoma of the skin was 1 in 32 for females (and I in 22 for males). Mortality (ASR) in females in WA for melanoma of the skin is up by 11.8% whereas there has been a 7.4% decline nationally.

There has been a greater increase (22.8%, 1988-1990) in the incidence of Breast cancer in women 50-74 years in WA. The national increase for the same period was just over half of this (12.9%). Breast cancer is the most common life-threatening cancer among women and the risk for developing the disease in Australia by 75 years of age is estimated to be around 1 in 14. Mortality from cervical cancer has declined, however there were still 27 deaths in WA in 1997. There remains a real need to increase participation in cervical screening for older women as 50% of cases of cervical cancer are in women over 50 who have either never had a Pap smear or not had one for some years.

Youth Health Project

The Youth Health project aims to address the health needs of young people at risk and train GPs to work more effectively with young people. These two aspects interact through the opportunity for GPs to take part in the GP Youth Health Training Course and work at a health clinic for young people that is run from Quarry Health, 7 Quarry St., Fremantle.

This training program has operated on an annual basis since 1996. Each year changes are made to ensure that the real needs of GPs are being addressed. The program is a support for the GPs working at the youth health clinic however other GPs interested in the area of youth health are welcome to attend. The program involves presentations as well as the opportunity for interaction and case discussions.

In 1999 eighteen GPs took part in the training program. The format included a one-day seminar followed by a series of 10 evening sessions. Topics covered included engaging and relating to young people, assessment, youth mental health, family and developmental issues, abuse, alcohol and drugs, sexual health, resources for young people and risk taking behaviour.

A similar program is planned for the first half of 2000. GPs are welcome to attend some or all of the sessions, although preference is given to those able to take part in the whole program.

Linked to the youth health training course for GPs is a clinical audit task involving the assessment of consultations with 20 patients aged between 12 and 25. Areas assessed include the type of patient seen and the problems addressed. The task involves an analysis of the data highlighting areas of strengths and weakness in dealing with young people in general practice. The aim is to look at ways of building on the strengths and reducing the weaknesses so that care for young people can be improved.

The emphasis of the clinic is on health issues specific to young people such as sexual health, abuse issues, relationship problems, drug/alcohol issues, depression, diet, lifestyle issues and STDs, hepatitis C and HIV. Set in a youth friendly environment the clinic operates on long appointment times so that there is the opportunity to deal with complex issues.

MAJOR ACHIEVEMENTS

It is important to note that the number of active programs increased markedly in the previous two and half year period with significant work achieved in the highly successful Quality Use of Medicines Program, collaboration in National initiatives for Immunisation and Computerisation, and an expanded Community Liaison program.

Continued OBF program activity in areas of National Health Goals and Targets were cardiac rehabilitation and women's cancer screening. Other areas of OBF program activity were in the integration of clinical nursing with general practice, aged care, and on-going consumer liaison. Other program activity managed by the FRDGP and funded by sources other than the Department of Health and Aged Care, included public and private hospital liaison, youth health, clinical research trials, CPR workshops and best practice in infection control.

Another core area of activity surrounded consumer participation and the work of the Consumer Reference Group (CRG). The program was expanded during the previous grant period to include a half-time project officer and further funds for consumer participation in Division activities. The CRG has now been established as a designated program in the current plan. The goal of the FRDGP is to integrate effective consumer participation in all aspects of program development and management.

GP participation is a fundamental element in the success of Division programs. The FRDGP enjoys a high level of GP membership and active participation from the local GP population. Improved GP awareness of the benefits of Division membership and associated services, via strategies such as the appointment of a Director of GP Support Services, are high priorities in the context of a rapidly changing general practice environment.

The FRDGP has been required to expand premises and infrastructure resources to cater for a high level of activity and growth. Further expansion of the physical setup for the Division is likely to occur in the next period as a result of new programs including "Getting Patients Treated" and a possible Coordinated Care Trial in aged care. Collaboration with other stakeholders, e.g. Care Options Inc., and the National Prescribing Service, as active partners in shared programs, was also a key feature of recent Division achievements. The enhanced capacity that comes from collaboration with other Divisions and other public and private organisations will continue to be a central strategy for the FRDGP.

These principles follow from an analysis of the Division's previous resource allocation which revealed an emphasis on programs targeting individual health gain for advantaged groups contrasted with a new, preferred approach, to allocating resources to maximise benefits for groups in the community recognised as disadvantaged in their health status.

Consistent with these strategic directions existing programs that will continue with modified outcomes include changing Women's Cancer Screening to Women's Health more broadly. This program will also be involved in a statewide Pap smear audit.

Healthy Hearts (cardiac rehabilitation) will be transformed to include a sustainable privately funded component, increased GP communication and tailored health promotion and community liaison for targeted disadvantaged groups. Identification of disadvantaged groups and appropriate intervention strategies for GPs and the Division will be addressed in a Needs Analysis project.

The FRDGP's collaborative Quality Use of Medicines (QUM) program will continue with a range of activities including a local GP clinical audit and the DiNCQUM GP consortium at a national level. The Fremantle and Osborne Divisions will also continue their joint initiatives funded by the National Prescribing Service.

The long running Hospital Liaison Program will continue with Fremantle and St John of God (Murdoch) Hospitals. Both public and private GP Hospital Liaison is funded via consultancy agreements with the hospitals.

The upcoming block grant period has also presented the challenge of continuing services from the block grant that were previously funded by separate Commonwealth funding. This is the case for the continuation of the IM/IT program aimed at increasing the uptake of computers in general practice. A user pays system will be introduced in combination with a block grant allocation to support the continuation of a full-time service. The Immunisation program was also funded by separate Commonwealth funds and will continue to December 2000 funded from monies unspent to 30 June 2000.

The FRDGP's long standing and highly successful Consumer Reference Group (CRG) will continue with the support of a part-time Community Liaison Officer. The area of community liaison has received an increase in overall budget to further support health promotion and community liaison activities throughout all aspects of the Divisions programs.

The Division's GP Education program will continue with an increase in allocation for a CME coordinator to enhance the integration and efficiency of program-based and other Division education.

Areas of activity not highlighted in previous plans include Integration and GP Support and Communication. These "services to GP" activities are not new to the FRDGP, however, they have increased strategic importance for the Division in maintaining it's relevance to GP members. Responding to changes in the general practice environment and the expressed wishes of GP members, the FRDGP believes these areas are best represented as discrete programs with clear outcomes and indicators.

Aged Care also has a new look capturing the work undertaken in the Women's health and QUM programs. The establishment of a Coordinated Care Trial in aged care is also a significant initiative in the upcoming block grant period.

It should also be noted that the Division is progressing projects funded by the 1999 round of Innovation Grants.

Works funded by two grants and one seeding project relate to IM/IT applications for guideline management of diabetes titled "Qpath", application of information management in QUM for better patient outcomes and the development of improved linkages between GP and allied health and community-based health care (Integrated Care).

A very a high level of growth and activity was evident in the previous block grant period. An increasing role for Divisions of General Practice per se in the health system is likely to require continued adaptation and flexibility. The challenges before the FRDGP are to maintain a high level of effective GP participation and a sustainable, diversified funding base. One of the keys to addressing these challenges is to continue to foster a strong sense of commitment and teamwork amongst the Division's staff and members.

The Division's Project Officer staff has evolved significantly in recent years. It presently comprises 15 employed staff equivalent to 9 FTE. The range of professional backgrounds and experience represented in the Division's staff includes medical science, general practice research, counseling, organisational psychology, clinical psychology, hospital and community nursing, health promotion, adult education, accounting and business management.

The FRDGP's high quality team of staff demonstrates an invaluable degree of commitment to the goals and values of the FRDGP.

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