National Health Reform

Building a 21st Century Primary Health Care System: A Draft of Australia's First National Primary Health Care Strategy

Building Blocks for a 21st Century Primary Health Care System

1. Regional integration

The current proliferation of primary health care services (across program types, sectors, providers and funders) makes it difficult for either patients or providers to navigate the health system with assurance and for consistent high quality outcomes to be achieved. While this is particularly the case for people with complex care needs and those with historically poor access (such as Indigenous Australians or those living in rural and remote areas) it is equally the case for people who are hard to reach, such as the homeless or those with mental health needs, those needing specialist care or those moving in and out of the hospital system.

A key challenge for primary health care reform is to better integrate and coordinate the range of organisations and service providers operating within primary health care and to better link primary health care and other sectors.

Developing networks, encouraging partnerships and establishing new integrated service delivery arrangements requires multiple changes, particularly at the local level to:

• enable collaboration and integration between local service providers to focus on the needs of individual patients;
• support service planning and monitoring of effectiveness and patient outcomes, to reduce duplication and fill gaps; and
• allow flexibility to deliver supplementary services that respond to priority local needs.

Many of these changes could be implemented through a regional governance structure with:

• strong local leadership and community engagement and support;
• clear performance expectations both in terms of identifying population needs and being accountable for progress in meeting those needs; and
• funding to drive integration, provide education and training, support change management and ensure gaps in local service delivery arrangements are filled.

Notably, regional primary health care organisations could manage supplementary funding, targeting those elements of the service system where proactive engagement has the capacity to address traditional areas of market failure, and drive improved outcomes and system efficiencies. Such areas include chronic disease management, a focus on prevention, supporting patient transitions and integrating service responses across the system (including linking to the acute and specialist care sectors).

Responsible regional primary health care organisations could also have a role in reflecting on system effectiveness and relative cost-effectiveness, informing decisions on allocative efficiency across the broader health system, and adapting service solutions to respond to emerging challenges such as changes to clinical practice and new technologies.

What will be different? Less overlap and duplication of services, with better use of the existing workforce. Health care providers and their patients no longer having to navigate the system, trying to patch together care pathways.

2. Information and technology, including eHealth

eHealth and other technologies are key enablers for change in primary health care. eHealth will allow information to be available when and where a patient needs care, can drive communication and partnerships between providers and with patients, will reduce the risks of adverse events for consumers and, with it, reduce costs and improve patient outcomes.

Electronic information exchange, particularly individual electronic health records (IEHRs), are a strong support for multi-disciplinary primary health care collaboration and enable efficient exchange of information between the primary health care, community and specialist health care settings.

This would be a significant improvement on the current situation for clinicians and consumers, particularly those with complex or chronic health conditions and those who need to move across the service system – from a general practice to a specialist service provider or allied health professional to a hospital and back.

As Australians increasingly access online information and services through mobile and e-technologies, they expect that the health sector will operate as does other sectors, affording them similar access, efficiencies and ease of information and connection.

Consumers expect to be involved and active in their health care management, and should have access to tools to enable self-care in a structured and informed way, and assist them to navigate the health system maze effectively.

Released in December 2008, the National E-Health Strategy provides an appropriate basis to guide the development of eHealth and proposes the incremental adoption of IEHRs. The National Health Call Centre Network, a Council of Australian Governments (COAG) funded initiative, provides a good infrastructure base for other innovative uses of technology, such as proactive telephone-based self-management support of patients and online health information.

What will be different? Patients not having to repeat their medical history to each new provider. Patients having information to help them to manage their own condition. Health care providers able to set up virtual, integrated care teams, and having accurate and timely information to support best treatment. Potential to outreach to hard to service communities with more innovative and efficient use of health workforce. Improved quality and safety.

3. Skilled workforce

It is essential that the future workforce is educated and trained to meet 21st century challenges but in a way that provides the flexibility and willingness to continually reflect on its role and place in the health care team to ensure that skilled resources are used in the most effective and efficient way as clinical practice and teams change.

Through COAG’s recent investment in health workforce, community-based clinical training will expand, to provide a future workforce skilled in the delivery of increasingly complex care, in the community setting, and adept at working in multi-disciplinary teams. As a result, GP training places will increase by 33% on the cap of 600 places imposed since 2004. In 2009, the Australian Government allocated an increase of 1,134 higher education nursing places, and these are ongoing.

For the current workforce, working in a changing environment will involve greater understanding of the respective roles of other health professionals, development of arrangements for collaboration and teamwork, proficiency with technology and eHealth and enhanced skills in supporting individuals in health literacy and self-management, including changing risky lifestyle behaviours.

What will be different? Patients having improved access to primary health care providers and better integration of their care. Providers being equipped with the skills they need, supported in learning, and able to pass on hard-earned skills to students and new graduates.

4. Infrastructure

The right physical facilities and equipment are important catalysts for new models of primary health care delivery. Multi-disciplinary services require consulting rooms for the range of team members, for group activities, for team meetings and case planning discussions. Good facilities are important to support outreach services, including services delivered by visiting specialists. The right physical infrastructure is important in extending community-based health professional education, including inter-disciplinary and virtual training opportunities. Encouraging active research within primary health care service delivery requires the right spaces and equipment to create the primary health care 'laboratory'.

New and enhanced facilities could include comprehensive primary health care services - one stop shops offering a wide range of services - or smaller enhancements to private general practices to support a broader team, teaching or visiting sessions from other health professionals.

Through the GP Super Clinics initiative, the National Rural and Remote Health Infrastructure Program and the COAG National Partnership Agreement on Hospital and Health Workforce Reform, much progress has already been made in recognising the importance of infrastructure.

What will be different? Patients having improved convenience of access to services, including co-location of services for patients seeing multiple providers. Providers having resources to support changed training and workplace arrangements, allowing for more flexible working arrangements. Primary health care system facilitating the distribution of services and promoting service integration.

5. Financing and system performance

The right mix of financial incentives and funding arrangements is a key underpinning to ensure that service delivery models work effectively and responsively. Traditional Medicare rebates have a place in promoting reasonable access to health services for many in the population, and in underwriting general practice as small business – itself an important part of access. However, the MBS has been less effective in producing better outcomes for

at-risk and hard to reach groups, in promoting collaboration across and within various parts of the health system and in adapting to changing population pressures and clinical challenges. The uncapped nature of the MBS has meant that attempts to extend coverage to address emerging health needs or under-serviced groups soon hit cost barriers resulting in artificial rules being created to contain costs.
Changes to funding arrangements need to reduce the reliance on fee-for-service, support alternative funding mechanisms that better support effective integrated teams and models of care, encourage innovation, and respond to local service gaps.

Over time, changes need to be informed by evidence, including increasing consideration of cost-effectiveness and the relative efficiency of different approaches across the spectrum of care options including self-management. The system of the future needs to use outcomes data and performance information at population, population subgroup, regional and practice levels to promote reflection about what works well and where improvements could be made. Creating a self-reflective and adaptable service system is a key to long term system sustainability and to achieve sustained improvements in patient outcomes.

What will be different? Patients having access to a greater range of affordable services. Funding for services better aligned with need. Providers, funders and policy makers having better performance information to improve practice and monitor system performance.