Comparing general practice in Australia and in England: an Australian perspective and the RCGP International and Overseas Network

Participation as a founder member of the International and Overseas Network (ION) of the Royal College of General Practitioners (RCGP) presented me with the fortuitous opportunity and challenge to pause, to reflect, and to take stock of my experience of life as a GP in Australia and as a GP in England. This article compares and contrasts the primary healthcare systems in both countries from the vista of the individual, practising GP working in those systems, and considers the approaches and developments that each system might learn from the other.

Following 20 years as a coalface GP, who has also held various NHS management and healthcare leadership teaching positions, I departed the UK with my family in 2016 to follow my wife as she stepped forward to accept an exciting new corporate job opportunity. Contented as a GP in England, emigrating — for me, as an individual — was categorically about ‘moving towards something new’ rather than an expression of dissatisfaction with my career or life in England.1 

Frequent immersion back in the UK — five visits in 18 months, interspersed between growth and consolidation of experience in Australia — has allowed for an evolving and reflexive2 overview3 of the two health systems from the standpoint of the individual GP.

My experience in England was as a GP practising in a relatively affluent socioeconomic locale. My Australian experience is in a similar socioeconomic urban setting. As such, my reflections are drawn from comparing and contrasting the healthcare systems’ impact in these specific contexts. GPs practising in rural and remote settings, or those working with indigenous communities, will have different experiences of the UK and Australia. Further, a variety of healthcare reforms are underway in Australia which will alter this experience, just as UK …


Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
Last summer our small medical team visited the Calais 'Jungle'.Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone.Some youngsters are finally being brought to the UK under the 'Dubs' amendment.However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.

July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence.The finger was partially degloved.He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected.He is in danger of losing his finger.
A middle-aged Sudanese man has been having rigors and is generally unwell.He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency.The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle.They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see.How can we arrange secondary care for the young Afghan in danger of losing his finger?We try to persuade him to return to the original local hospital, but he is reluctant.It was not a good experience for him the first time round.
With the other two patients, it is easier.They can attend the Salam clinic run by a local association during weekdays.Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night.We examine a severely malnourished 2-year-old boy.We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation.We learn that there is inadequate safeguarding in place to protect them.A young Eritrean man comes in worried about his eye.He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye.We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1).

The reality
These are no ordinary patients.They have travelled far from home to escape war, poverty, and misery.They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations.Many have survived the loss of their families, torture, and rape.Their journeys over, for the moment at least, they must make their homes in the Calais Jungle.Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground.They own next to nothing.There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life.They are vulnerable to exploitation, crime, injury, and disease.Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far

Introduction
Participation as a founder member of the International and Overseas Network (ION) of the Royal College of General Practitioners (RCGP) presented me with the fortuitous opportunity and challenge to pause, to reflect, and to take stock of my experience of life as a GP in Australia and as a GP in England.This article compares and contrasts the primary healthcare systems in both countries from the vista of the individual, practising GP working in those systems, and considers the approaches and developments that each system might learn from the other.
Following 20 years as a coalface GP, who has also held various NHS management and healthcare leadership teaching positions, I departed the UK with my family in 2016 to follow my wife as she stepped forward to accept an exciting new corporate job opportunity.Contented as a GP in England, emigrating -for me, as an individual -was categorically about 'moving towards something new' rather than an expression of dissatisfaction with my career or life in England. 1 Frequent immersion back in the UK -five visits in 18 months, interspersed between growth and consolidation of experience in Australia -has allowed for an evolving and reflexive 2 overview 3 of the two health systems from the standpoint of the individual GP.
My experience in England was as a GP practising in a relatively affluent socioeconomic locale.My Australian experience is in a similar socioeconomic urban setting.As such, my reflections are drawn from comparing and contrasting the healthcare systems' impact in these specific contexts.GPs practising in rural and remote settings, or those working with indigenous communities, will have different experiences of the UK and Australia.Further, a variety of healthcare reforms are underway in Australia which will alter this experience, just as UK general practice will change and develop with new policies and initiatives.
What then, from my personal case-study experiences, would I suggest Australia learn from the UK and the UK learn from Australia?
The global financial crisis (GFC) hit health services hard across Europe, 4 whereas Australia -'The Lucky Country' -remained relatively unscathed. 5he GFC, like any environmental shock, represented a seismic threat and also an opportunity to all sections of society and the economy, including health care. 4he impact as a British GP was austerity, severe funding cuts, a recruitment crisis, and the 'scorched earth event' that created ecological space to offer promising disruptive technologies 6 the niche to take root and thrive.The period from 2010-2016 saw the growing, day-by-day impact on me, as a GP and a practice-owner, of innovations such as the NHS e-referrals service, 7 and the electronic prescriptions service. 8NHS policy placed digital technology promotion centre-stage, and cultural changes encouraged full patient access to their digital records. 9,10otwithstanding the failures, the fudges, and the frustrations of technology implementation, and of staff adoption and adaptation, the net impact as a practitioner in the UK is a system where the infrastructure -the 'train tracks' -for digital transformation exist.This allows the individual GP to encourage patients and their families to access their full medical records, including clinical progress notes, results, and hospital letters; it enables patients to view information online before and after consultations using 'safe search' options facilitated by their GP practice; and it allows GPs to make optimal use of m-health and app technologies to interact with patients in between their consultations. 11,12ustralia has the My Health Record online health summary initiative, 13 and many examples of available homegrown and overseas-produced apps, 14 but the infrastructure that might offer patients the choice to undertake an online search comparing public health providers, to access their full medical records as opposed to a summary, or to request and receive prescriptions via a completely digital prescribing service are not currently in place.
It's noticeable how the primary care system in Australia gives less prominence to nurses in urban settings: advanced nurse practitioner consultations and chronic disease management clinics have burgeoned in the UK, following the pressures on the NHS, whereas in Australia, doctors are frequently involved in work that's typically nurse-led in the UK, such as assessing wounds, recommending dressings, and managing travel immunisations.The distinct funding models -item-of-service in Australia, and capitation in the UK -are the likely root causes for these differences and drivers for efficiency. 15at might the UK learn from Australia?
Patients and practitioners in Australia are aware, and are reminded every day, of the cost of each healthcare interaction: practitioners are required to bill the patient via Medicare, 16 our national health system, for each service provided to a patient.Each consultation attracts a fee, and Medicare reimburses patients a fixed dollar amount for GP consultations.Patients are used to paying for many aspects of health care and there are no completely free prescriptions for any resident, regardless of age, but an annual safety net guarantees a maximum amount each year each Australian will pay before the state steps in to shoulder the burden.A safety net also exists for our Australian Aboriginal and Torres Strait Islander patients.The net impact, for me, feels like a more open and transparent discussion about money, and the cost of doing business in health care in Australia.This contrasts with what often feels like the perennial pressure to conjure yet another efficiency rabbit out of the shrinking NHS budget hat.Patients in Australia can arguably exercise more agency in exploring their public and private healthcare options, and innovators seem to be more able to test out new approaches thanks to direct funding by satisfied consumers, rather than wading through the interminable NHS procurement process which will inevitably favour larger incumbents rather than promising new start-ups.GPs also have the flexibility to request additional patient co-payments for their services, and patients are free to shop around for services from other providers.This can mean, for example, charging a premium for peak-hour evening and weekend services, while requiring no additional payment for less popular daytime services.The net result is a healthcare conversation about money which -in the urban, affluent environment in which I practice in Australia -feels refreshing and empowering to patients, compared to our culture of 'free health care is a right that I am owed' in the UK.However, this is not the case, I understand, for GPs who work with indigenous communities and disadvantaged populations, where service and prescription fees certainly do act as a significant barrier to healthcare equity. 17at would I suggest to my GP colleagues in Australia?
Australia ducked the burning platform of the GFC, but risks being slowly boiled by the economic pressures faced by all other OECD (Organisation for Economic Co-operation and Development) healthcare systems. 18As individual GPs, and as members of larger state and national organisations, we need to anticipate this future, and embrace opportunities now to trial and test promising disruptive digital technologies and novel teamworking practices that maximise rather than retrench skill-mix.

What would I suggest to GP colleagues in the UK?
Make healthcare costs more evident and obvious to the British public.A bill for each GP consultation, for each medicine based on its actual cost, for each allied health professional attendance, for each hospital stay with a subsequent line item demonstrating the 100% NHS rebate.Explore the possibility of opening up patient choice, to allow co-payment for non-standard GP services; practice-based dermatology or fee-paying telephone consultations at the weekend with a named GP partner, for example.This might encourage a shift in attitudes towards the place of money and costs in health care, and our patients may arguably become, in transactional 19 terms, more empowered and equal partners rather than dependent recipients.The potential value of these ideas would have been lost to me, and may well have seemed disturbing, when all I knew was life as a GP in the NHS.
Australia and UK have the second and the first rankings, respectively, in a review of healthcare systems 17 conducted by the Commonwealth Fund.This report highlighted strengths and areas for improvement that each healthcare system could learn from others.Indeed, it is likely that each healthcare system around the world has something to teach and something to learn.Flying visits by the great and the good are one thing, but true organisational learning is probably most helped by immersion. 20The RCGP, the Royal Australian College of General Practitioners, and their sister colleges around the world could best help their members by examining ways to streamline mutual recognition, and to lobby to facilitate the easy movement of GPs between countries to allow for sabbaticals and exchanges: we, as practitioners, will gain from the rich contrast in experience; our practices will gain from new and complementary skillsets; our profession will gain from a reimagining of what and how health care can function; and the sum total of this activity could help to invigorate standards and experiences of quality health care for our patients.