status quo of quo vadis? - KCE

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36 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 Figure 2. The Australian quality framework (with the permission of Teri Snowdon, RACGP) This paper also analyses specific quality development initiatives i.e. certification, fellowship, feedback on prescription, peer review, practice accreditation, practice incentives programmes, audits, networks of general practice. CERTIFICATION Australian doctors are required to obtain Fellowship of the Royal College to be designated as general practitioners. Doctors without any fellowship are called ‘Other Medical Practitioners’ and usually receive a lower Medicare rebate for the services provided. However, given a significant workforce shortage, some of these doctors have been allowed to work with full Medicare rebate in ‘areas of need’: they are supposed to participate in programs to achieve their College fellowship. The certification relates to consultation behaviour and patient management. Indicators are test ordering (e.g., prostate antigen screening), referral for diabetes, cardiovascular risks, prescription rates. 77 FELLOWSHIP Fellowship is the standard of competence for working unsupervised in Australian general practice. The fellowship can be gained through various pathways. The vocational training programme is the most common one, after a conjoined examination and having worked under supervision. 128 All general practitioners must participate in a quality assurance and continuing professional development program (QA&CPD) to maintain their credential. That program recognises clinical audit, small group learning, clinical attachments, research, participation in higher education courses and writing for professional journals as well as participating in workshops. FEEDBACKS ON PRESCRIPTIONS Medicare annually provides prescription and pathology data to the GPs. This initiative is supported by an independent organisation, the National Prescribing Service that employs facilitators and academic detailing. 124 PEER REVIEW Peer review is at an experimental stage and not mandatory in the Australian model. 52 PRACTICE ACCREDITATION Australia has a system of general practice accreditation with standards for practices determined by the RACGP.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 37 The measurement against those standards is carried out by two independent bodies i.e., AGPAL (Australian General Practices Accreditation Limited, non-profit) and for-profit Quality Practice Accreditation Limited. 129 Practices need to register for accreditation and indicate when a survey visit can take place. Before the practice visit, the GP or the practice performs a self assessment. Two surveyors assess the practice against the standards, criteria and a range of indicators. These indicators mainly relate to the organisation and infrastructure of the practice. The accreditation body coordinates with the practice to find a mutually agreeable date and the practice is surveyed against the RACGP standards. Clinical indicators are not yet used except for some preventive measures like cervical smears and immunisation programmes, for which special remuneration is available and data centrally collected. 130 In July 2003, 87% of practices in Australia had undertaken accreditation against the RACGP standards. 131 Some practices are in their third (three year) cycle. The costs are approximately 2200-2500 euros for a visit to a group practice. The practice accreditation leads to an increase of income. The practice is allowed to enrol in the Practice Incentive Programme that may increase the income by some 6300 euros. PRACTICE INCENTIVE PROGRAM Since 1998, Australia introduced the Practice Incentive Program, which offers financial incentives to practices working towards accreditation. Payments relate to aspects of general practice that contribute to quality care. These include the use of IT, provision of after-hours care, student teaching and better prescribing. Practices in rural and remote locations gain additional subsidies. The payments relate to the number of patients but not to the number of consultations. This in turn offers a gateway to remuneration of services like information management and technology, after hours care and student teaching. 132 AUDIT Audit is not of major importance in Australia. NETWORKS OF GENERAL PRACTICE Divisions are regional networks of GPs that offer services to GPs and their practices. Australia has 120 Divisions. They work under the umbrella of the Australian General Practice Network. The Divisions of general practice play a fundamental role in the changes of general practice. In particular, quality development is their core business. 133 Priority areas include governance, prevention, access to health care, supporting integration and multidisciplinary care, better management of chronic diseases, general practice support, quality support, consumer focus and Workforce support. 134 2.4.5.3 Evidence for effectiveness In 2004 more than 2610 practices have taken re-accreditation. Raw data indicate that many items of their practice organisation improved. For instance 6,2 % of practices introduced a system to enhance the follow up of abnormal test results. 123 An econometric analysis showed that there is a relation over time between the introduction of the Divisions and many improvements measured by performance indicators (for instance immunisation coverage, chronic disease management items, percentage of practices receiving cervical sign payments). However, the data do not allow inferring any causal relationship. Division characteristics mostly relate to various measures of practice infrastructure. The budget devoted to the divisions was estimated about 5 euros per capita. 134 2.4.5.4 Future developments The quality framework for Australian general practice introduces basics concepts for quality development like the creation of a climate oriented towards quality, advice to use indicators and peer review with a ‘no-blame culture’. Unlike the UK example this framework much more focuses on formative effects.
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