Nutrition & Dietetics 2009; 66: 7273

DOI: 10.1111/j.1747-0080.2009.01346.x

LEADING ARTICLE

Primary health care: The new frontier. Are dietitians on the front line or just bring up the rear?
ndi_1346 72..73

Delivery of health care in Australia is changing rapidly, driven by a number of factors, including population demographics, technology, the rise of chronic disease and the escalating and arguably unsustainable cost of the current models of care. The current raft of federal government taskforces and enquiries directed at health care reform14 are a clear indication that business as usual is no longer an option. Jurisdictional control and systems are being closely examined and traditional service provision and professional boundaries challenged. Hospitals, and a role for the hospital dietitian, will always be there, but there is a clear move towards enhancing primary health care (including prevention and early intervention) in the community and elevating it to the main delivery platform for health care into the future. Keeping people well and managing chronic conditions outside the acute hospital and residential aged care settings as much as possible is the preferred and only affordable option. The exact structures to support quality models of care are yet to be worked out, but are likely to involve a mix of fee for service, salaried community or practice-based positions and outreach programs based on a regional structure. In parallel to this development is the increasing awareness of the role of nutrition in the prevention and management of chronic conditions, and everyone wants a piece of the action. If dietitians are not there leading the way in nutrition, then someone else will do it for us. Some are already exing their muscles. If dietitians cannot directly deliver the care or interventions, then they need to be leading the training of other health workers and be involved in managing and evaluating the programs. Are we ready to lead? Are we ready to face the challenges and take the necessary risks to be recognised as the experts in nutrition in primary care? Delivery of quality dietetic services, in the multidisciplinary primary care setting, requires both ideological and logistical shifts and not only from dietitians. We need to be able to demonstrate our value in a competitive environment and the current evidence supporting dietetics in primary care is limited. This is an important area for research. Primary health care is the territory of the advanced generalist. For many years, general practitioners (GPs) were seen as jack of all trades, master of none and there has been a similar mentality in dietetics, but the landscape is changing. Specialisation has its place, but ongoing skilled management of a range of often inextricably linked chronic conditions is a large part of our future as a profession. Collaboration and 72

communication between those working in specialised areas and the primary care generalist are needed to ensure best practice and good outcomes for patients across the continuum of care. Do we actually have the capacity to deliver? There have been a fairly small percentage of dietitians in community health and more recently in divisions of general practice and outreach programs involved in both public health nutrition and community dietetics. There has also been a latter day surge in dietitians entering private practice,5 especially since the advent of the allied health items in Medicare. Despite this, only a minority of dietitians work full time in a private practice, with many working only very limited hours often as a sideline to their substantive positions. Primary health care now requires considerable focus and engagement and to be successful in this area, dietitians need to be able to provide an excellent, accessible and sustainable service. To fail to do this risks the reputation of the profession and will result in dietitians being marginalised from primary care provision. There is little question that GPs who know and understand the role of dietitians value their services. The papers by Pomeroy and Worsley6,7 in this issue and statistics for uptake of the Medicare allied health items8 clearly support this. However, a recent survey undertaken by Dietitians Association of Australia (unpublished) indicates that many GPs do not really know what dietitians can offer, do not know what their qualications are, have trouble locating them and are most comfortable referring to allied health practitioners they know and whose service they can depend on. The reality is that there are not enough practitioners out there to meet demand at present and many that are out there may not be effectively marketing their skills and services. It is partially a question of economics, but a number of dietitians have set up viable and growing full-time practices.9 Perhaps the greatest challenge, and one that will require true innovation, is to ensure that we can deliver primary care dietetics to those in rural and remote areas or areas of social disadvantage. One of the fundamentals of ongoing chronic disease management is multidisciplinary team care. This is a signicant enough challenge when everyone is colocated. It is an even greater challenge when practitioners are in independent private practice or state-funded community health centres effectively separated from fee for service providers. It requires excellent systems, strong interdisciplinary knowledge and rst-class communication practices, another issue highlighted by Pomeroy and Worsley.7 2009 The Author Journal compilation 2009 Dietitians Association of Australia

Leading article

The future of integrated primary care requires multidisciplinary practice guidelines, well-designed e-health solutions, interdisciplinary professional development and interdisciplinary integration of aspects of entry-level education and practical placement opportunities. This will require reorientation in both the education and health sectors and will challenge the current silos of entry-level training and ongoing professional development. The challenge of providing adequate opportunities for professional practice in the primary care setting, especially in private practice, needs to be addressed. GPs realised some time ago that to get highly skilled young doctors to choose general practice and do it well, they needed to offer them that experience in their training.10 This requires practices (both solely dietetics and multidisciplinary) that are in a position to provide quality practical placement. It will also require innovation on the part of the training schools. Systems to support and nurture inexperienced practitioners in the primary care setting, especially private practice, are vital. This can be provided to some extent by existing professional networks, but the move towards group practices may suggest that GPs nd sole practice unviable both nancially and professionally, and this is likely to be the case for dietitians. As dietitians are more exposed as a profession to the primary care area, their practice comes under greater public scrutiny and the need to ensure safe, high-quality and ethical practice is of paramount importance. To be successful in the primary care sector, and not just in private practice, dietitians need to enhance their core dietetic skills with marketing and business skills, to collaborate in practice-based research and involve themselves in the development of multidisciplinary, evidence-based guidelines. Taking the primary health care road to practice is an exciting opportunity but needs to be embarked upon with a clear understanding of what is required and the knowledge that to some extent the territory is uncharted. Claire Hewat, BSc(Hons) Dip Nutr&Diet, APD Executive Director, Dietitians Association of Australia and Chair, National Primary Health Care Partnership Deakin, Australian Capital Territory, Australia

REFERENCES
1 National Hospital and Health Care Reform Commission. National Hospital and Health Care Reform Commission website. (Accessed 1 April 2009.) Available from URL http:// www.nhhrc.org.au 2 Preventative Health Taskforce. Preventative Health Taskforce website. (Accessed 1 April 2009.) Available from URL: http:// www.preventativehealth.org.au 3 Australian Government Department of Health and Ageing. National Primary Health Care Strategy. Department of Health and Ageing, 2008. (Accessed 1 April 2009.) Available from URL: http://www.health.gov.au/primaryhealthstrategy 4 Australian Government Productivity Commission. Australias Health Workforce Research Report. Australian Government Productivity Commission, 2006. (Accessed 1 April 2009.). Available from URL: http://www.pc.gov.au/projects/study/ healthworkforce/docs/nalreport 5 DAA. Dietitians Association of Australia annual membership statistics reports 2003, 2004, 2005, 2006, 2007. Available from DAA National Ofce, 1/8 Phipps Close Deakin ACT Australia. 6 Pomeroy S, Worsley A. Contribution of Australian cardiologists, general practitioners, and dietitians to adult cardiac patients dietary behavioural change. Nutr & Diet 2009; 66: 7480. 7 Pomeroy S, Worsley A. Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians. Nutr & Diet 2009; 66: 8186. 8 Australian Government Medicare Australia. Medicare Benet Scheme Statistics. Medicare Australia, 2009. (Accessed 1 April 2009.) Available from URL: http://www.medicare.gov.au/ provider/medicare/mbs.jsp 9 DAA. Dietitians Association of Australia Annual Reports 2008 and 2006 Presidents Awards for Innovation. Available from DAA National Ofce, 1/8 Phipps Close Deakin ACT Australia. 10 Royal Australian College of General Practitioners. Prevocational training. (Accessed 1 April 2009.) Available from URL: http:// www.racgp.org.au/prevocational

2009 The Author Journal compilation 2009 Dietitians Association of Australia

73