Primary Health Strategy

Towards a National Primary Health Care Strategy: A Discussion Paper from the Australian Government

The Discussion Paper 'Towards a National Primary Health Care Strategy' provides information and a series of questions to assist individuals and organisations to structure their input to development of the Strategy through written submission, by the end of Februrary 2009.

PDF printable version of the Discussion Paper (PDF 920 KB)
If you have any difficulty accessing the PDF, please contact pacdweb@health.gov.au


Follow the links for futher details on the Consultation Process and the Consultation Submission Form (RTF 41 KB).

Foreword

Our health, the health of our families, and being able to access the health care services we need, are issues of prime importance to us all. This is why the Rudd Government is committed to improving our health care system, and has initiated an extensive program of health care reform.

We know that preventative care, primary health care and acute care are all intertwined and interdependent elements of our health system – and our reform agenda acknowledges that interconnection.

Improvements in primary health care are critical to improvements in the overall health system. In particular, primary health care is vital in turning our health care system more towards keeping people well and participating in life and work, rather than just looking after people when they are sick.

Our commitment to developing Australia’s first National Primary Health Care Strategy is a key element of this reform process. Primary health care is the part of the health system most Australians use most often and it is supported by many dedicated and hard working health professionals. It is part of our lives, from birth to death, and when we need it, it is usually our link to the other parts of the health system.

We need to have a primary health care system that enables people to see the right health professional for their needs, in an appropriate place at the right time.

In an era with an increasing burden of chronic disease, that health professional may be their local GP, it may be the general practice nurse, a nurse practitioner or it may be an allied health professional, such as a psychologist, physiotherapist or dietician.

This Discussion Paper canvasses important issues. Many of them warrant discussion and a number are likely to result in debate. I would encourage you to participate in this process, so that we can get the best possible result for all of us in Australia who depend on world class health services.



The Hon Nicola Roxon MP
Minister for Health and Ageing

From Dr Tony Hobbs Chair of the External Reference Group

As a General Practitioner in rural Australia, I have recently been involved in the establishment of the Cootamundra Primary Health Centre - a new multidisciplinary clinic. I am excited by the opportunities that this new centre provides to deliver quality primary health care to the people in the Cootamundra area. At the same time, I am somewhat frustrated by some of the constraints in the current program and funding arrangements, which impede our capacity to deliver the integrated services most needed in our local community. On a broader scale, I am concerned at the inequities in health care and health outcomes experienced by the more vulnerable groups across Australia, particularly Indigenous Australians and those living in our rural and remote areas.

I know for many health care professionals and consumers, the development of Australia’s first National Primary Health Care Strategy has been long awaited. It is an opportunity to look carefully at those aspects of our current system which are not working well, and to move towards a system which allows the best use of our professional skills in delivering the health care services needed in our communities.

I look forward to working with the External Reference Group, the Minister, and the Department of Health and Ageing in this important endeavour, and I join with Minister Roxon in encouraging your participation.



Dr Tony Hobbs
Chair, External Reference Group

Preface

Process for development of Australia’s National Primary Health Care Strategy

The Australian Government has committed to the development of Australia’s first National Primary Health Care Strategy (‘the Strategy’).
Developing the Strategy will require consideration of a wide range of issues associated with the current planning, delivery, governance and financing of primary health care services in Australia, some of which cut across Commonwealth, state and territory responsibilities.

Future directions and reforms, to be identified through the Strategy, will need to recognise and build on the many aspects of our system which are working well. Importantly, the Strategy needs to recognise the critical contribution of the many dedicated health care professionals who are delivering services in our communities.

An External Reference Group (ERG) of health experts has been convened to support the Government in developing the Strategy. The ERG has membership based on expertise in, and commitment to, primary health care in Australia, and includes General Practitioners (GPs), a nurse, allied health professionals, academics, a pharmacist, and a consumer representative. The ERG is expected to meet frequently during 2008-09. The ERG Membership and Terms of Reference are available on the Strategy website at: http://www.health.gov.au/primaryhealthstrategy

Communication with a broad range of stakeholders about the Strategy and consultation on proposed elements will be critical to its long term success. Input and comment on this Discussion Paper is sought from the broad public, state and territory governments, professional and consumer groups, and other interested people and organisations.

In formulating the draft Strategy, the Department of Health and Ageing (DoHA), working with the ERG, will draw on the information it receives from submissions, research and expertise assembled from other sources, including through engagement with other health reform processes.

A draft Strategy is expected to be available for consideration by the Minister for Health and Ageing by mid 2009.

This Discussion Paper is intended to provide a broad framework and basic information on key issues impacting on primary health care. Its purpose is to stimulate input and comment to assist in the development of the Strategy.

This Paper proposes 10 elements which could underpin a future primary health care system and for each one provides a snapshot of:

• What happens now?
• What does this mean for the community and health consumers?
• What does this mean for health professionals?
• Where could changes be made?

Input on any aspects of these 10 elements, or on additional matters relevant to the Strategy, is welcome.

How to provide input or comment

You are invited to provide written input or comment on this Discussion Paper. Submissions can be sent by post or email.

Content of submissions

Your submission should include:

• name and full contact details (including email address), company name (where applicable) and designation of submitter. A form for providing this information can be found on the Strategy website at: http://www.health.gov.au/primaryhealthstrategy
• comment on areas/questions in the Discussion Paper that are of interest to you;
• any other relevant information (for example, any technical, economic or business information, or research-based evidence) supporting your comments and views; and
• identification and discussion of any perceived omissions in the Discussion Paper or alternative approaches.

Confidentiality of submissions

Unless otherwise indicated in the submission, all submissions will be published on the Department of Health and Ageing website. If you wish any information contained in your submission to be treated as confidential, please explicitly and clearly identify that information, and outline the reasons why you consider it to be confidential. Note that general disclaimers in covering emails will not be interpreted as a specific request or taken as sufficient reason for submissions to be treated confidentially. Any submissions which include personal information identifying specific individuals will be de-identified before submissions are published.
In addition, where submissions focus on issues specifically relevant to state and territory governments, this information may be forwarded to the relevant jurisdiction(s).

Address for submissions

Electronic submissions should be emailed to: nphcs@health.gov.au
Hard copy submissions should be sent to the following address:

National Primary Health Care Strategy Secretariat
MDP 94, GPO Box 9848
CANBERRA ACT 2601

Questions relating to submissions

Any questions relating to submissions should be directed to the NPHCS Secretariat, by email at: nphcs@health.gov.au

Deadline for submissions

The deadline for receipt of submissions is Friday, 27 February 2009.

Introduction

Health care is a priority issue for all Australians.

Generally, our health system is high performing and compares well with overseas health systems. However, for some population groups there are barriers to accessing health care, and health outcomes are uneven, raising questions of equity and fairness. The gap in life expectancy between Indigenous and non-Indigenous Australians is the most telling example, but not the only case.

Primary health care is the frontline of Australia’s health care system. While many Australians may not recognise the term ‘primary health care’, it is a term used to refer to the parts of the health system that most people interact with most of the time. For example, around 18 million ¹ Australians see a GP at least once a year.

In addition to GPs, primary health care services involve a range of health care providers including nurses (such as general practice nurses, community nurses and nurse practitioners), midwives, allied health professionals, pharmacists and dentists. In Australia, primary health care is delivered through a combination of publicly and privately provided services (funded through Commonwealth, state and territory, and private arrangements), including through private health insurance funding.

This Discussion Paper is not based on a precise definition or boundary for what should, or should not be, considered as ‘primary health care’. While there are a number of definitions available, including from the World Health Organisation² and the Australian Primary Health Care Research Institute³ , in practice there is no absolute or consistent view about whether particular settings and services are part of primary health care or not. At this stage, and to allow for Submissions to address possible future directions without being unduly constrained by current service and funding arrangements, the scope of primary health care is left broad.

Alongside the development of the National Primary Health Care Strategy (‘the Strategy’), other key reform processes include the:

• Council of Australian Governments (COAG) Health and Ageing Working Group⁴ ;
• National Health and Hospitals Reform Commission (NHHRC)⁵;
• Preventative Health Taskforce (PHT)⁶; and
• Review of Maternity Services⁷.

As part of each of these processes, important issues relating to primary health care in Australia are being considered, which can be expected to inform the development of the Strategy.

Another important and related process is the development of the National eHealth Strategy, which will have the potential to enable system change to support delivery of broader reforms across the Australian health care system and improve health care delivery.

A review of the Medicare Benefits Schedule (MBS) primary care items is also being undertaken by DoHA alongside development of the Strategy – with a focus on reducing red tape for doctors, simplifying the MBS, and giving more support to preventive health care.

In addition, a number of reviews and long-term planning processes are being undertaken in specific areas relevant to primary health care (eg. review of rural health programs, development of a Fourth National Mental Health Plan and the work of the National Advisory Council on Mental Health) which will link with development of the Strategy.

Consumers and stakeholders have shown a very strong interest in health care reform. For example, the 2020 Summit received over 1,100 health care related submissions, and the NHHRC submission process has received over 500. Many issues and suggestions proposed through these submissions are relevant to primary health care.

Why a National Primary Health Care Strategy?

While overall Australia’s health care system performs well, we face real challenges with a growing burden of chronic disease, an ageing population, and health workforce pressures. At the same time, the complexity and volume of care delivered and required in the community continues to increase through:

• changes in hospital services through reductions in length of stay, increased day surgery and, in some rural areas, reduction or closure of hospital services;
• an increased focus on ageing at home;
• an increase in care being provided to people in their homes (eg. dialysis, chemotherapy etc) that was previously provided in hospital;
• ongoing impacts of de-institutionalisation in a number of areas, notably mental health and disability;
• new technologies which can support alternative models of community based care and have the potential to allow the delivery of some services closer to a patient’s home; and
• better knowledge and expectations of best practice care at both the health provider and patient level.

Responses to these issues, to date, have been incremental. The result is a primary health care system in Australia characterised by an increasing proliferation of narrowly targeted programs and funding arrangements, and growing complexity and inflexibility for health care organisations, professionals and consumers.

Within primary health care, the Commonwealth has funded subsidised care provided by GPs through the MBS. Over recent years, the MBS primary care items have grown in number and complexity and now include limited access to rebates for some services provided by other health professionals. At the same time, and partly in response to limitations in MBS arrangements, a range of alternative initiatives for blended and targeted payments have been introduced, including the Practice Incentives Program (PIP). The PIP has provided incentives for a range of quality focussed activities in general practice. State and territory governments are also increasingly focussed on primary health care, with a number of jurisdictions having primary health care strategies in place. Alongside state and territory governments’ traditional community health activities, jurisdictions are funding a range of primary and ambulatory care programs, (primarily targeted at hospital avoidance, such as Victoria’s Hospital Admission Risk Program). All jurisdictions are increasingly engaging with private general practice.

An important focus of these jurisdictional programs is to improve integration between Commonwealth, state and territory funded primary health care services, aimed at reducing fragmentation and improving the patient journey. These have included programs such as the Primary Care Partnerships in Victoria and the Connecting Healthcare in Communities initiative in Queensland which have focussed on improving relationships between service providers in regional areas. As well, state programs focussed on integrated primary care service delivery models include the NSW’s HealthOne NSW initiative and South Australia’s GP Plus initiative.

The introduction of more flexible private health insurance arrangements has also increased the scope for private health insurers to engage with primary health care in the development of programs which reduce the need for hospital admission. This has the potential to supplement the range of allied health services traditionally funded or supported through private health insurance.

In this Discussion Paper, current challenges and future directions have been grouped around four key themes: quality of care and health outcomes for consumers; health care service delivery arrangements; health workforce capacity issues; and fiscal sustainability.

The Paper focuses more on the potential areas for improvement than on describing current successes. While, as noted above, Australia’s health system performs well, this paper is designed to encourage consideration of future changes required to address existing shortfalls.

The development of a national Strategy provides an opportunity to address these issues through a comprehensive and consultative approach, to help ensure that Australians have the best possible primary health care system to face future challenges.

What are the key elements of an enhanced primary health care system?

This Discussion Paper proposes 10 key elements which could underpin a future Australian primary health care system:

All Australians should have access to primary health care services which keep people well and manage ill-health by being:

1. Accessible, clinically and culturally appropriate, timely and affordable;
2. Patient-centred and supportive of health literacy, self-management and individual preference;
3. More focussed on preventive care, including support of healthy lifestyles;
4. Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing, and complex conditions.

Service delivery arrangements should support:

5. Safe, high quality care which is continually improving through relevant research and innovation;
6. Better management of health information, underpinned by efficient and effective use of eHealth;
7. Flexibility to best respond to local community needs and circumstances through sustainable and efficient operational models.

Supporting the primary health care workforce are:

8. Working environments and conditions which attract, support and retain workforce;
9. High quality education and training arrangements for both new and existing workforce.

Primary health care is:

10.Fiscally sustainable, efficient and cost effective.Key to the proposed Strategy and implicit in all 10 elements, is a focus on ensuring greater equity not only in access to services, but also in health outcomes for all Australians, and on delivering a primary health care system where accountabilities for performance and outcomes are more transparent.
Question:
Are there aspects of a future Australian primary health care system that are not included in these key elements?

1. Accessible, clinically and culturally appropriate, timely and affordable

Objective: All Australians have access to required primary health care services, which are clinically and culturally appropriate to their needs and circumstances, and are delivered in a timely and affordable manner.

What happens now?

At the core of an effective health system is good access to services – being able to see the right health professional, at the right time, in the right place: and in a manner that is affordable and culturally appropriate. Supported by the MBS, most Australians have relatively good access to affordable GP services – with an average of 5.1 GP services per capita, and 79.1% of GP services bulk billed. ⁸ However, access is not uniform, with some parts of Australia and some population groups experiencing gaps in available GP services and closed books, long waits and/or travel for appointments, or higher out-of-pocket costs to see a GP. There are also barriers to access to quality of care especially longer consultations, preventive care, and referral to allied health providers.⁹
These barriers can relate to cost, time and distance, or the lack of services which are culturally appropriate and accessible to the needs of particular groups.



Further, funding through the MBS has historically focussed solely on medical arrangements. In recent times this has been extended to a small subset of other nursing, midwifery, dental and allied health services. Services provided by allied health professionals (such as psychologists, physiotherapists, and dieticians) and dentists are funded through a variety of approaches (privately, including through private health insurance, through state and territory government programs, limited MBS access¹⁰ , and other Australian Government programs). This means that access to allied health and dental services can vary depending on factors such as:

• an individual’s condition – with government subsidised services available for some health conditions but not others;
• geographical location – with variations even within jurisdictions in the availability and timeliness of publicly funded allied health and dental services; and
• insurance cover, or ability to pay privately, which will not always relate to an individual’s capacity to pay.

While the importance of multidisciplinary teams in providing primary health care services is increasingly recognised, team-based models of care can be restricted by current program and funding arrangements. For example, while in many practices general practice nurses (subsidised through the PIP in certain areas) are playing a progressively more important role, the funding arrangements to support advanced nursing services including by nurse practitioners are limited. Pharmacists also are increasingly providing professional services and advice as well as traditional dispensing services. Dental health has traditionally had less support than other medical services. The Australian Government recognises the importance of providing equitable access to dental services for those most in need.

At the same time, current funding arrangements also mean that some health professionals may be providing some aspects of care which could be delivered equally effectively by another health professional.

What does this mean for the community and health consumers?

While Australians overall are satisfied with their primary health care services,¹¹ this is not universal. For some population groups, including Indigenous communities, the homeless and people with a disability or mental illness, access to the range of primary health care services they need is limited. Similarly, those living in some rural, remote and lower socio economic urban areas are receiving fewer services, and not necessarily the range of services from different health professionals they need. Also, for those with complex care needs, access to the full range of services they need can be difficult - due to waiting times for public services or out of pocket costs for private services.Lack of access to primary health care services can result in poorer health outcomes, unnecessary and potentially avoidable complications, and hospital admissions. It also means that some people present at emergency departments for primary health care services.

Cath is a single parent who lives in a small, rural area with her two children. Cath has depression and cardiovascular disease, and her youngest child has asthma. Both require regular medication and visits to the medical practice in the nearby town. The waiting time for a normal appointment at their practice is usually five days. A standard consultation at the practice includes an out of pocket payment of around $20, but Cath and her child are usually bulk-billed, with the practice receiving an incentive payment for bulk-billing services to concession card holders and children. Cath has been referred for psychological therapy to help address her depression, with the nearest psychologist located in the regional centre, 125 kilometres away. The psychologist charges a co-payment on top of the Medicare rebate.

For Cath the biggest problems are having to travel to see her GP and psychologist, the lead times to get appointments, and the need to meet her family’s other health care needs and the costs associated with this.

What does this mean for health professionals?

In some instances, availability of services and funding arrangements, rather than clinical need alone, may impact on the primary health care that professionals can provide. For example, less time may be spent on prevention or lifestyle focussed activities, as funding arrangements do not sufficiently support these activities, nor delegation to another health professional or referral to another service. Providers may also face inefficient referral pathways, or complex program eligibility criteria in trying to access the services their patients need.

Where could changes be made?

Resources for health spending are not unlimited and our health workforce is under pressure. Primary health care service delivery and funding arrangements need to ensure:

• affordable access to necessary services for all communities, with current inequalities reduced or eliminated;
• access to services based on clinical need; and
• health professionals making best use of their skills, in a team environment.

Questions:

• How can we ensure appropriate services for all geographical areas and population groups?
• How could primary health care services/workforce be expanded to improve access to necessary services?
• What more needs to be done for disadvantaged groups to support more equitable access?
• With limited public health dollars, how could priorities for accessing primary health care services be determined and targeting of public resources improved?

2. Patient-centred and supportive of health literacy, self-management and individual preference

Objective: Primary health care services respond to the individual preferences and circumstances of patients, their families, and carers, and actively support them in achieving best possible health outcomes.

What happens now?

This element is about a primary health care system which is designed around supporting the patient, their family and carer(s), to be in control and actively supported in decision-making regarding their care. It is also about a system which is easy for them to use, and helps them to manage their health care needs and stay as healthy as possible. Often referred to as patient or person-centred care, this involves health professionals considering the patient as an individual within a social network – where his/her experiences, preferences, values and needs are taken into account in the planning and delivery of their health care – in a way which considers the patient journey in their health care encounter.

Along with recognition of an individual’s role in decision making about their health care, patient-centred care supports their role in self-care and monitoring.¹² In Australia, there is evidence that suggests health literacy (i.e. a person’s ability to find, process and understand basic health information needed to make appropriate health decisions) for some people is below what is required to effectively engage with the health system and manage their own self care. ¹³ Also, not all health professionals have the necessary range of skills and opportunities needed to support patients’ self management.

These issues are worse for particular groups, where a lack of culturally appropriate services can work against patients’ engagement with health services. Examples include Indigenous Australians, some other culturally and linguistically diverse (CALD) populations, and those who have disabilities, drug or alcohol dependency, or mental health conditions. Lack of Indigenous identification by mainstream health services can impact on their accessing of appropriate services.

There is scope for many health care organisations in Australia to improve and/or introduce mechanisms for effective consumer engagement and input. While the Royal Australian College of General Practitioner’s (RACGP) accreditation standards for general practice include a patient feedback questionnaire, measuring consumer experiences in primary health care has had limited application in Australia to date.

What does this mean for the community and health consumers?

Lack of a patient-centred focus from health care services can mean care is fragmented, patients are poorly informed about their care needs and options and there can be gaps and/or duplication of services received. These factors can be compounded by poor self management skills, low levels of health literacy, a lack of readily available, reliable and consumer friendly information, and limited health practitioner support.
Overall, this can lead to poor adherence to treatment regimes, limited success with reduction in lifestyle related risk factors and worsening clinical outcomes. Without effective engagement with local communities, services and information provided are less likely to be relevant or culturally appropriate.

Greg is in his mid 40s and has asthma and related breathing difficulties. Greg tends to see GPs at one of two local practices or a medical clinic when feeling unwell, and has presented to Accident and Emergency at his local hospital when he has had asthma attacks (twice in the last six months). One GP provided a generic asthma management plan for Greg at a previous visit but Greg has not complied with it and does not use asthma preventer and reliever medications as directed, or regularly enough. Greg has been a heavy smoker most of his adult life and though he has cut down, he continues to smoke. Although advised to quit smoking, exercise more and lose weight, Greg has yet to take up this advice and may need better support and information to help him change his lifestyle.

Greg does not have a clear understanding of his condition and what sorts of things are likely to provoke an asthma attack. The treatment and advice he has received to date has tended to focus on the problem of his asthma, not on Greg’s overall health needs as a person, including what he needs to manage his asthma, and how to address the barriers that are preventing him from making lifestyle changes.

What does this mean for health professionals?

While health professionals are taught principles of patient-centred care during their training, in some work environments there may be limited support, skills, tools and funding mechanisms available to put patients and their family at the centre of care. Instead, the system supports a focus on specific disease processes and managing episodes of care, rather than the ongoing care process or treatment path for the individual patient.

Where could changes be made?

A greater focus on patient-centred care is increasingly being identified as a key objective for health system reform. The Australian Safety and Quality Commission, in their background paper for the development of a Consumer Engagement Strategy¹⁴ has identified that a person-centred health care system would:

• emphasise attention to patients’ and consumers’ psychosocial as well as physical needs – that is, focus on the holistic needs of the patient;
• focus on a ‘partnership in care’ between patients, their carers and their health professionals;
• facilitate active patient involvement in decision-making about treatment and lifestyle options, including taking personal preference and needs into account; and
• promote effective self-care to support adherence to agreed treatment options and in achieving related necessary behaviour changes.

It is also important that consumer self-management education programs are better integrated with primary health care.


Questions:

• What is needed to improve the patient and family-centred focus of primary health care in Australia for:
• individual patient encounters;
• health professionals;
• health service organisations;
• the broader primary health care system?
• Are there specific strategies that are needed to better support consumer engagement and input?

3. More focussed on preventive care, including support of healthy lifestyles

Objective: All Australians are supported to stay healthy through a stronger focus on wellness, prevention and early detection, and appropriate intervention to maintain people in as optimal health as possible.

What happens now?

Primary health care has tended to respond to problems already affecting the patient, with the need for treatment and care usually being initiated by the patient. Historically, there has been less attention to preventing the occurrence of problems and maintaining good health. There is scope for a greater focus on preventive care, that is, interventions to detect and reduce the risk of disease and of complications from an existing disease, including supporting individuals with the behavioural changes required to reduce lifestyle risks such as poor diet, lack of exercise or smoking.

The RACGP ‘Green Book’ notes, for example, that of a typical 100 adult patients seen by a GP 20 – 30 would not have had their lipids tested in the past five years, and that 10 – 15 would not have had their blood pressure measured in the past two years.¹⁵

Not only in general practice, but in other primary health care services, the scope and extent of preventive activity is restricted. Research also suggests low rates of detection for many significant conditions with, for example, evidence that 50% of people with diabetes and 75% of people with Chronic Obstructive Pulmonary Disease (COPD) were not aware that they had the condition .^{16 , 17}

At the same time, the prevalence of key risk factors associated with chronic disease is increasing.¹⁸ Factors contributing to the gap between optimal and current preventive practice include constraints on clinician time, what is funded in primary health care and the method of financing, the limited availability and utilisation of other health professionals, notably allied health professionals, to provide preventive health services, limited engagement with self-management education, consumer understanding/acceptance of lifestyle modification, and lack of quality data, information and decision support systems ¹⁹ People who do not access, or who have limited access to primary health care, are also significantly disadvantaged in relation to preventive health care.

What does this mean for the community and health consumers?

Some groups have increased risk of diseases because of social, cultural, socioeconomic or other factors (eg, their place of residence, economic resources, employment status, skills, low levels of education, language and cultural barriers and lifestyles).²⁰ These factors can make it hard to make changes or adhere to advice on diet, smoking, drinking and other lifestyle behaviours. For example, some people can find it hard to adopt a healthy diet, because it can be more expensive than one based on foods that are high in fat, salt and sugar.

What does this mean for health professionals?

Preventive care requires approaches that are evidence-based, systematic and sustainable. The RACGP’s ‘Red’ and ‘Green’ books, strategies such as the Smoking, Nutrition, Alcohol and Physical Activity Framework, and tools such as disease registers and recall and reminder systems are available to support this aim. However, without a systematic and integrated process to guide this work, primary health care professionals are often left to deal with preventive health on an ad-hoc basis while addressing the more urgent demands to diagnose and treat ill-health.

Where could changes be made?

A more systematic approach to preventive care in our primary health care system could involve:

• improved measurement, clinician monitoring and reporting of preventive activity, supported by financial and non-financial incentives;
• financial incentives for primary health care providers to incorporate the provision of appropriate/targeted screening services, health checks, and preventive interventions consistent with evidence-based guidelines as part of ongoing care, and to achieve outcomes in these areas (eg. not just detecting smoking but assisting the patient to quit smoking);
• linking or affiliating patients with primary health care providers to support population-based preventive health care, including incentives to providers and consumers;
• improved referral pathway options for risk factor modification and lifestyle related services;
• improving access to allied health services for preventive care; and
• targeted prevention activities, including targeted recall and follow-up systems, for particular at risk populations, including socially disadvantaged persons, people in rural and remote communities, and Indigenous communities.

Questions:

• How could primary health care be enhanced to better support prevention activities?
• How could health professionals be better supported to provide lifestyle modification advice and support consumers in behavioural change?
• How can consumers be linked with local primary health care services to support a stronger focus on population-based preventive health care with national reporting?
• What measures have been, or could be, effective in addressing prevention for specific population groups (eg. Indigenous, rural and remote, low socio-economic status, CALD)?
• With limited public health dollars, how could preventive care priorities be determined and public resources subsequently targeted?

4. Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing and complex conditions

Objective: All Australians, particularly those with multiple, ongoing and complex conditions, experience primary health care services which are coordinated across multiple care providers, with transitions across health sectors actively managed and continuity of care supported.

What happens now?

Australia’s primary health care system is a complex mix of Commonwealth, state and territory, and privately funded and delivered services. While it performs reasonably well for many, for the growing number of people with chronic disease, and especially those with multiple and complex conditions, this is not the case.²¹ These people generally have multiple complex health care needs, often provided in different settings and by different health professionals and are often at risk of experiencing an acute event. For these patients, the need to navigate their own way through the system and between multiple services and health care providers can be a daunting experience, with poor coordination leading to worsening outcomes, preventable acute events and emergency department and hospital admissions. With an ageing population, and a growing prevalence and burden of chronic disease, these issues will only become more acute.

Poor linkages between general practice and state and territory funded services, including hospitals, community health and other community based services, can adversely impact on patient care, for example, through inadequate planning and coordination on discharge from hospital. This may leave patients without clear advice on how to manage their medication, or leave their GP or aged care provider without sufficient knowledge of the treatments the patient has undergone or the services and medications required to care for the patient.

Patients can also be affected by lack of coordination or fragmented care between health care service delivery organisations and providers. This can create problems such as: the ordering of duplicate tests; lack of follow-up; conflicting information from different health care providers; and not receiving the appropriate level of care at the right time.²²

What does this mean for the community and health consumers?

Especially for those with complex care needs, navigating their way through a complex and increasingly costly and fragmented system can be a source of frustration and difficulty for patients, their carers and families, and can result in adverse outcomes and unnecessary complications. For those with relatively poor access to services, such as in rural and remote areas, lack of ready access to up-to-date and accurate information can impact on the care provided and on patient outcomes. Not all patients and their families have the capacity to co-ordinate their own care, and patients with complex needs, in particular, often require support to navigate through the health system.

What does this mean for health professionals?

While recognising the patient’s role in managing their own health needs, overall responsibility for coordinating clinical aspects of care generally falls to a patient’s GP. In many instances, lack of any other options may also see a patient’s GP involved in coordinating other aspects of care including daily living support services.

While most people in Australia tend to see the same GP or practice for their primary health care (and in this sense are informally affiliated with a health provider for ongoing care), this is different to patient enrolment as used in other countries. Many patient enrolment schemes include active involvement by the patient’s primary health care provider in the ongoing management and care of the patient, often with an expectation and incentives to manage the overall health of their enrolled population group. Often, and especially for patients with multiple, ongoing and complex conditions, poor communication and information transfer means that the range of health professionals involved are not well informed of all aspects of care the patient may be receiving, and are therefore constrained in supporting the patient’s overall care. Navigating a complex system on behalf of a patient can be a significant and time consuming activity for health professionals.

Fiona is 62 years old. She suffers from Type 2 Diabetes and hypertension. Her diabetes is managed by medication, diet and exercise. She regularly visits her local general practice for routine health care including prescriptions and treatment of minor ailments. Her GP has recently completed an MBS GP Management Plan and Team Care Arrangements in consultation with the local pharmacist and podiatrist. With these arrangements in place she is seeing the podiatrist using MBS subsidised-services. Fiona also attends the diabetes out-patient clinic at the local public hospital where she sees the endocrinologist and diabetes educator. Recently, her GP has referred her to a private cardiologist for further investigation because her blood pressure had become harder to control. The cardiologist prescribed a new medication which she filled at a different pharmacy near his rooms.

Fiona is receiving care from six different health professionals and services, relying on multiple funding arrangements, and is taking five different medications (including over the counter preparations). No single person or organisation has complete information on, or responsibility for, her care.

Where could changes be made?

A number of Commonwealth, state and territory initiatives have been introduced to support more integrated care. This is also a core objective for GP Super Clinics. These initiatives have been positive, but there remains scope for significant further improvements. Many of those with complex needs would benefit from active support in managing their condition and coordinating their care needs. There should be clear accountability for the total care of the patient, and effective communication and collaboration between the various providers involved.
While co-location of service providers is one approach, alternative approaches to integrating service delivery and improving the patient journey for this high need group are also required. The development of an Individual Electronic Health Record (IEHR) has the potential to assist with the management of chronic and complex conditions across multiple care providers and health sectors to ensure continuity of care.


Questions:

• What target groups would most benefit from active clinical care and/or service coordination?
• Who is best placed to coordinate the clinical and/or service aspects of care?
• How could information and accountability for patient handover between settings (eg. hospital and general practice) be improved?
• What changes are needed to improve integration between different primary health care organisations?
• What sorts of advantages would there be if patients had the opportunity to ‘enrol’ with a key provider?
• Would there be advantages in patients having the opportunity to ‘enrol’ with a key provider?

5. Safe, high-quality care which is continually improving through relevant research and innovation

Objective: All Australians have access to safe, high quality primary health care services that deliver evidence-based care and accountability for outcomes, support continuous quality improvement, and reward research and innovation.

What happens now?

There is relatively little information on the performance of primary health care services in respect to safety and quality, consumer outcomes or consumer experiences. To date, accreditation has often been used as an indicator for measuring safety and quality of primary health care services. The Quality Improvement Council runs a national scheme that accredits over three hundred primary health and community support agencies. A national approach to GP accreditation has resulted in 80% of patient care being provided by GP practices that are accredited against nationally agreed standards developed by the RACGP.²³

Increasingly, supported by Divisions of General Practice and programs such as the Australian Primary Care Collaboratives and the National Prescribing Service, health professionals are looking at clinical performance indicators and other mechanisms (including pay for performance) to drive quality care, and support greater accountability for whole-of-population health outcomes. In addition, the PIP also supports quality primary health care through a range of specific incentives.

Delivering best practice care requires a sound evidence-base, but rigorously designed studies are relatively under-represented in primary health care research. ²⁴

Formal and informal clinical networks for promoting and sharing learning regarding innovative models of primary health care tend to operate outside of national frameworks, meaning that the outputs and outcomes they may be achieving are not well-known or taken up more broadly. There is an increasing proliferation of guidelines and other best practice information, but their authorship, status, relevance, and quality may not be clear to health care providers. For those working in primary health care, disease specific guidelines developed for the hospital or specialist setting are often not relevant or useful for managing patients with ‘multi-morbidities’.²⁵

There is an increasing emphasis in primary health care on the need to utilise continuous quality improvement (CQI) approaches to assessing models of care and to providing the evidence for what will work. CQI has potential to facilitate ongoing improvement in care and bring about substantial and sustained improvement in the quality of care. However time constraints, and a lack of financial incentives, have limited the potential for primary health care professionals to be involved in research and CQI activities.

What does this mean for the community and health consumers?

In our current system, there is very little to inform and guide consumer awareness and assessment of the quality of individual health professionals or health care organisations. While consumers can look to accreditation of primary health care services as an indicator of quality of services, accreditation does not provide a measure of clinical performance, and is not well known or understood by health consumers. A lack of high-quality research and evidence to guide the development of guidelines, protocols and pathways means that communities and health consumers can receive variable or sub-optimal care, and face a greater risk of adverse events and medical misadventures.

What does this mean for health professionals?

Under the MBS, remuneration generally focuses on the activity involved in individual episodes of treatment. Health professionals are not supported to provide care that takes a whole-of-population focus, and do not always have the capacity and tools (eg. clinical decision support systems) to deliver evidence-based and best practice care. The involvement of primary health care professionals working at the coal face in research and CQI activities is vital, but lack of time, remuneration, non-recognition, or other barriers are currently limiting active participation.

Where could changes be made?

Areas for increased focus include:

• improved targeting, funding and better dissemination of research – including on which interventions are the most effective for which populations groups;
• options for making a clinical academic career in primary health care more attractive;
• expanded capacity for primary health care providers to collect, record and use data, and to monitor performance, including health outcomes;
• meaningful performance measurement (such as indicators or standards) to support evidence-based clinical care and decision making;
• the importance of profession led models for assessing what constitutes evidence-based quality health care;
• improved strategies for communicating with primary health care professionals and consumers about high quality health care management strategies that have a strong evidence base;
• consideration of linking incentives for health care professionals to patient health outcomes and quality of care provided; and
• more robust systems of accreditation which also focus on more patient-focussed clinical outcomes and the quality of clinical care provided (for example, blood pressure control, hospital readmission rates, care coordination, or patient experiences).

Questions:

• What aspects of performance of the primary health care sector could be monitored and reported against (eg. for each Element in this Discussion Paper, what are key areas of performance that could be monitored and how)?
• Who should be responsible for developing and maintaining a performance framework?
• Would there be advantages in linking patient health outcomes and quality of care provided to incentives for health care professionals?
• How can we improve the current research culture and evidence-base in primary health care?
• How can we translate evidence or innovation into practice more systematically?
• What options could be used to support health care professionals’ involvement in research and innovation?

6. Better management of health information, underpinned by efficient and effective use of eHealth

Objective: Primary health care service arrangements benefit from greater sharing and improved access to health information, clinical knowledge resources and emerging technologies to better support patient-centred care.

What happens now?

The diversity and fragmentation of health care and funding models in Australia can lead to an experience that, for both the patient and provider, is often frustrating. There is potential for emerging electronic technologies to enable improved health care, to reduce barriers to health equity and to facilitate better access to medical technologies.

The term ‘eHealth’ encompasses the electronic management of health information and the systems that will support the secure use and transfer of health information. Implementation of eHealth by, and making effective use of, Information and Communications Technology (ICT) in primary health care requires changes to business practices within health care, which can be costly and time consuming.

Levels of computerisation in Australian general practice have increased over the last decade or so. A secondary analysis of the Bettering the Evaluation and Care of Health (‘BEACH’) survey conducted over 2007 and 2008 shows that the majority of GPs reported using a computer at work (96.7%) for the following purposes:

• electronic prescribing (92.3%);
• billing (89.4%);
• electronic medical records (85.6%);
• ordering tests (82.2%);
• other administrative (83.6%); and
• internet/email (81.5%).²⁶

However, it is apparent for a variety of reasons there is potential for GPs to more fully utilise the benefits of information technology.In broad terms, there is limited eHealth readiness in other key sectors of the Australian health system, such as hospitals, allied health, non-GP specialists and aged care facilities²⁷.This restricts effective coordination and transfer of information between the vast array of private and public health professionals and providers, including between general practice and private, state/territory or local government employed community and allied health services²⁸.

There has been some implementation of telehealth applications across Australia, especially in areas where advanced ICT applications can significantly reduce access barriers and improve quality of life and health care safety, particularly for people with chronic disease, or at risk of developing chronic conditions. These include the use of diagnostic, treatment and monitoring modalities, improved sharing of health information to facilitate team-based care, distance learning for health professionals and professional support, and access to reliable health information for patients and their carers. However, the introduction of such technologies is at an early stage and variable, with only some communities benefiting at this stage from a relatively small number of innovations.

There are also barriers to the adoption of new technologies (such as Internet approaches to home monitoring and videoconferencing) which can help to address current health pressures and to facilitate effective multidisciplinary or team communication. Current funding models provide limited support for electronic consultations or other forms of telemedicine (where a clinical service is provided by electronic communication).

What does this mean for the community and health consumers?

Consumer experiences of the primary health care system are often characterised by a constant need to repeat the same information and to retell their story to different health professionals. They are also affected by a lack of coordination amongst health professionals, and can experience unnecessary tests and procedures, medical errors and other complications related to poor information exchange. Confusing or misleading health information available on the Internet can also adversely affect outcomes.

Fiona was referred to under Element 4. She is 62 years old, and suffers from Type 2 Diabetes and hypertension. Fiona is receiving care from 6 different health professionals and services, and is taking 5 different medications (including over the counter preparations).

While her care plan will have the elements of treatment required, it does not have her medical record, and there is no formal mechanism for the different health professionals involved in managing Fiona’s condition to share their observations with each other. If Fiona requires treatment in a hospital, there will be no electronic discharge summary.

If Fiona had an Individual Electronic Health Record, able to be viewed by all her treating health professionals, she would not have to remember and repeat aspects of her medical history, nor the names of all her current pharmaceuticals. The health professionals involved in treating Fiona can have confidence that they have access to all the relevant information required to help them manage Fiona’s health, and that Fiona’s progress and reaction to different interventions can inform the approach of other treating clinicians.

What does this mean for health professionals?

Health professional experiences of the Australian health care system are often characterised by a lack of information sharing amongst health professionals. This can result in: limited ability to provide coordinated care to patients; lack of collaboration to support the provision of effective multidisciplinary care; poor referral pathways; potential for patient misadventure related to delayed or non arrival of referral information; and lack of electronic decision support tools to assist their patients to self manage their health and wellbeing.

Where could changes be made?

The way information is stored, used and shared across a complex and fragmented health system provides significant challenges to heath care. Better management of health information and the systems to support it are fundamental to enhanced primary health care delivery. There has been significant investment across Australia by all governments in eHealth, particularly in the development of key enabling eHealth infrastructure and standards and in the private sector, particularly in radiology and pathology. However further improvements and investments are still required, and could include:

• improved connectivity; interoperability, and scale-ability (including between and across Commonwealth, state and territory funded services and health sectors);
• greater support for primary health care providers to adopt and use eHealth solutions;
• strengthened partnerships across providers and care settings through effective health information exchange and referral supported by functionality, interoperability and security standards to protect privacy of patient information;
• implementation and use of telemedicine where the evidence supports its effectiveness;
• better use of ICT to support shared decision making, care planning coordination and review, and patient self management; self testing; and self monitoring;
• implementation and effective use of electronic patient information systems, including IEHRs that adequately address privacy and levels of access issues, and that support integrated service provision according to agreed national standards;
• development and use of integrated and evidence-based electronic quality and safety tools and resources to support best-practice clinical management; and
• performance benchmarking to identify the minimum patient data set that would be shared across providers.

Questions:

• What is the role for eHealth in supporting the provision of quality primary health care?
• Where should the Government prioritise its actions in relation to implementing eHealth reform?
• How can the various information systems be integrated (e.g. state health services and general practice)?

7. Flexibility to best respond to local community needs and circumstances through sustainable and efficient operational models

Objective: Primary health care services in Australia operate with an accountability and governance framework which is responsive to local needs, and is sustainable, flexible and well integrated with other non-health services in local communities.

What happens now?

There is growing acknowledgment that to be successful and sustainable, models of care need to be informed by the needs of local communities, and be responsive to the strengths and limitations of the environments in which people live. Changes in health behaviour occur when communities are informed about, and accept the need for change. A whole-of-community approach recognises the links between health care planning and other community issues or needs, such as improving the availability of fruit and vegetables at local food stores, and improving affordable access to medications.

Primary health care services in Australia are delivered predominantly by independent small businesses, Commonwealth funded targeted programs (focused on rural health, mental health, dental etc) or by state, territory and local government funded and/or auspiced organisations. Overlaying and supporting these is a range of organisations including: Divisions of General Practice; Area Health Services; Rural Workforce Agencies; Aboriginal and Torres Strait Islander primary health care services; Multi-Purpose Services and Regional Training providers with responsibilities for planning and delivery of aspects of primary health care.

At the local level there is variable, but relatively limited, scope for community engagement and fragmented regional planning exacerbated by different planning boundaries for different organisations. Divisions of General Practice, as a predominantly Commonwealth funded, regional infrastructure, have historically focussed on general practitioners, but are increasingly adopting a broader regional population focus. Currently around 30% of Divisions of General Practice have a community/consumer representative on their Board. At both the Commonwealth and jurisdictional level, recent initiatives have sought to enhance local integration and improve community engagement in both planning and service delivery, including links between health sector and non health services. Models of care (including preventive care) being trialled in more remote regions of Australia are starting to include a strong community development component, which has resulted in significant impact on community awareness of chronic disease, as well as an improvement in health outcomes amongst Indigenous people and other populations²⁹.

The establishment of GP ‘super clinics’ in areas of high need is one Commonwealth Government initiative which aims to respond to needs and priorities identified by local communities. GP Super Clinics will take an integrated and co-ordinated approach to delivering sustainable and efficient multidisciplinary models of care, including for chronic disease management.

However, there are inherent challenges in implementing new service delivery models (including co-locating services) which need to be carefully identified and addressed. Examples of challenges include impacts on existing services and workforce shortages, and relationship building across disciplines, health settings, and different organisations.

What does this mean for the community?

At the community level, the scope for community input to the planning and key direction of primary health care services is variable. Where opportunities exist, they will generally involve only a sub-set of services available within a community, and limited scope for realignment of resources between alternative priorities. Furthermore, the needs of some groups can be over looked without sufficient community engagement in local primary health care planning processes.

What does this mean for health professionals?

Individual health professionals will often contribute voluntarily to activities to improve primary health services in their local communities – sometimes with a sense of frustration in dealing with the complexity of multiple program arrangements and limited flexibility in addressing local priorities. In rural and remote areas particularly, health care providers may spend years building long-term connections with their community, but often with little or no recognition for the contribution this makes to providing continuity of care.

Where could changes be made?

There is a range of options which could strengthen community involvement in local service delivery planning, and provide primary health care that is more responsive to local needs and priorities. At the most fundamental level, there needs to be increased collaboration and engagement between the different services providers operating in a locality. A more comprehensive model could involve establishing regional level organisations that are responsible for activities ranging from planning, coordinating, to delivering health programs, and potentially allocating some elements of funding at the local level.
More generally, there is recognition that capacity for health service planning in Australia needs greater support. This can mean ensuring that all organisations involved in primary health care delivery and also relevant non-health services, are involved in this process locally, and that models of care are developed that:

• are sufficiently adaptable to address, and are appropriate to, local community needs;
• are flexible enough to be adaptable to the wide range of local environments that exist across Australia; and
• incorporate a high level of local community engagement in planning and delivery.

Questions:

• How could planning for primary health care services at the local level be improved?
• What advantages/disadvantages would there be in having a regional organisational structure with responsibilities (ranging from local planning through to service delivery) for primary health care services?
• Who could undertake this role? – What changes would be need to existing organisations (eg. Divisions of General Practice, Area Health Services) to undertake this?
• What advantages/disadvantages would there be if regional organisations were responsible for purchasing some primary health care services for their communities - that is, should they ‘hold funding’ for health services?
• What mechanisms could be used to improve the accountability of primary health care services being delivered in a locality (in respect to quality of care, reach and equity)?
• How can greater community engagement be supported in primary health care?
• What other approaches could improve planning and service integration at the local level?

8. Working environments and conditions which attract, support and retain workforce

Objective: Primary health care professionals work in environments which support a team-based approach and a work/life balance, with conditions that attract, support and retain a strong local workforce.

What happens now?

The 2008 Report on the Audit of Health Workforce in Rural and Regional Australia noted that the current supply of health professionals is insufficient to meet current needs. Importantly, the report also notes that distribution of the workforce is poor, declining significantly with greater remoteness.
In relation to medical practitioners, the report noted that while total doctor numbers continue to increase,³⁰ distribution of the workforce remains uneven and that the increased supply has not kept pace with population growth (and subsequent population needs). While recent increases in medical and other health professional university places will increase workforce supply, attracting these new entrants to primary health care generally, and to areas of greatest need, will be vital. Dental practitioners tend to be located in major metropolitan centres and access to dental services in regional and rural areas is relatively poor. Similar issues apply to most other primary health care professions.

Many GPs and other primary health care providers are also looking for greater work/life balance in their lives. Newly trained doctors and other health professionals want more flexibility in their careers and working conditions, which is not always possible under traditional models, particularly in regional areas. Also important is the need for appropriate professional support through locum services, being able to access training and education options, as well as peer support networks.

Increasingly, the primary health care workforce is moving toward team-based care to support new ways of delivering services where appropriate and relevant to the patient’s needs. Existing structural barriers including funding and remuneration arrangements and lack of appropriate physical or ICT infrastructure. Current indemnity and insurance arrangements pose some challenges to the development of team-based models of care.

An essential element of team-based care is the complementarity of professional skills and roles of general practitioners, general practice nurses, nurse practitioners and allied health workers. Making best use of the existing workforce is crucial, as in some instances, health professionals may be spending unnecessary time and resources on aspects of care that could safely and more efficiently be delivered by another health professional within the team. For example, while a physiotherapist can refer a patient to a specialist, under the current health system, for a patient to receive an MBS rebate for this service, the referral must come from a GP.Multi-disciplinary and team-based practice can also be supported by the emergence of newer work roles. For example, nurse practitioners and physician assistants have been used in primary health care in the United States, the United Kingdom and New Zealand for some time. Nurse practitioners are a small workforce in Australia currently, while the role of physician assistant is being trialed in several states.

What does this mean for the community and health consumers?

Across Australia, significant workforce shortages have impacted on people’s ability to access primary health care services in affected regions. For those with chronic or complex conditions who need to access a range of services, they may not currently be receiving the right care from the appropriate health professional in a timely and cost efficient manner. Patients can wait weeks for an appointment to see their GP, and even longer for other medical specialists and allied health services, especially in rural areas. Health care provided can be inconsistent from an ever changing local health workforce, or nonexistent. Having to travel long distances or pay significant out-of-pocket costs associated with accessing services impacts on optimal management of a patient’s health condition and adherence to agreed treatment plans. Workforce shortages can delay necessary treatment, impacting on quality of care provided, quality of life experienced and, sometimes, life expectancy.

What does this mean for health professionals?

Lack of a full range of health professionals in at least some settings means that primary health care professionals are limited in the support they can offer to their patients to self manage their health conditions, and in the opportunity to work with other health professionals to provide team-based care. Access to continuing professional development options is curtailed by limited opportunities and time available. Social support, family considerations and financial considerations mean that fewer health professionals are choosing to work in rural and remote regions, or other areas of high need (such as outer metropolitan areas), leaving a small number of health professionals, often overseas trained with a limited background in the Australian health care environment, to service more areas, and leaving other areas unserviced.

Where could changes be made?

Newer models or changes to existing models of workforce need to be explored, with a focus on:

• flexible working and training arrangements and sound business models that allow health professionals to combine their personal, family and work responsibilities and to make best use of existing resources;
• in rural and remote communities particularly, alternative models such as ‘hub-and-spoke’ or ‘walk-in-walk out’ models; and innovative e-health models to tackle issues of distance and professional isolation;
• expanding current opportunities for health professionals to have a varied professional life (eg. supporting the specialisation of GPs in procedural skills or pursuing other special interests; having opportunities to be part of local professional networks, e.g. the Allied Health Leaders Network);
• expanded specialist outreach services;
• professional definitions of roles, responsibilities and competencies for the current and future health workforce;
• removing existing barriers to team based care and utilising the existing workforce in a smarter way;
• consideration of new models of service delivery that utilise newer workforce roles;
• support for change management processes and trialling new workforce models; and
• improved criteria to determine areas of workforce shortage to increase community access to necessary primary health care.

Questions:

• What changes in working arrangements and conditions will better support primary health care professionals?
• How is teamwork facilitated in primary health care services and between them?
• How could the general practice nurse role be developed and enhanced?
• How can newer models of care or newer workforce roles (such as nurse practitioners and physician assistants) better support health professionals to meet demands created by a changing primary health care environment?
• Are there specific changes needed in those regions or populations where there is difficulty attracting and retaining staff?
• What funding arrangement could best support team-based care?
• How is it determined who is best placed to lead in multi-disciplinary team arrangements?
• Are other changes needed to current roles and responsibilities (eg. for prescribing and referral rights to be extended to non-GPs and specialists)?

The Homewood Practice has five doctors, two nurses, four administrative staff including a practice manager, and a part time visiting dietician and a podiatrist. There is strong leadership by the principal GP and practice manager. This encourages teamwork by ensuring that staff roles are defined and the value of each member’s work is recognised. There are procedures for communication including regular team and clinical meetings with action plans which are minuted. The acknowledged benefits of teamwork include staff stability and happiness leading to greater longevity of staff and less absenteeism. The principal of this practice has a passion for quality improvement and listens to the staff so she can take on board the ongoing changes required. One of the staff describes it as “a place where everybody feels motivated, accepted as an important member of the team, where issues can be brought up”.

9. High-quality education and training arrangements for both new and existing workforce

Objective: The current and future primary health care workforce is provided with high quality education (undergraduate, postgraduate and vocational) and clinical training opportunities that support interdisciplinary learning.

What happens now?

Education and training arrangements for health professionals are discipline specific, with teaching the future health care workforce undertaken by health professionals committed to teaching. While incentives do exist to support education and training, these are often not considered to be easily obtainable or of sufficiently high value for training to be financially viable for small organisations.

The recent increases in the number of undergraduate university training places will provide additional graduates in the coming years and is therefore a key step towards addressing workforce shortages. However, these increases need to be matched by a parallel growth in the capacity of the health system to deliver high quality education and training for students, and a continued and expanding interest in pursuing primary health care careers in order for this investment to translate into an enhanced and appropriately trained primary health care workforce. For example, only 27% of recent Australian medical graduates have entered general practice rather than other specialties.³¹

The funding and management of this education and training is specific to the professionals being taught and the stage of training that they are in (undergraduate, prevocational and vocational training), structurally limiting the ability of the system to support more cost effective vertical training models. Vertical training models which encourage teaching of junior doctors by specialists in training, and teaching of medical students by junior doctors, have the potential to produce more effective and cost-effective high quality training opportunities.

For non-medical professions, with the exception of pharmacy, the scope and support for community based training is even more limited. For allied health, for example, most clinical training currently occurs in the acute setting. Critical shortages of clinical training places for allied health professionals, and the lack of support for community based training is limiting an increase in tertiary training for some professions. Despite the growing importance of general practice nurses in the primary health care workforce, the undergraduate, post-graduate and continuing education needs of this group are not consistently addressed.

General practices are essential to delivering community-based training for medical students, junior doctors and general practitioners in training, and potentially also for nursing and allied health. Within the sector, both the physical facilities and GP teaching capacity is limited – with many current GP supervisors nearing retirement and fewer younger GPs taking up a teaching role. In this context, delivery of education and training opportunities is a key objective of the GP Super Clinic program. While this will address physical infrastructure and allow new training models in some of these localities, the fragmentation of existing arrangements with separate funding and governance streams for different levels of training (undergraduate, junior doctor and registrar) and lack of support for allied health and nursing training will continue to limit innovation unless addressed separately.

Further concerns have been raised regarding whether standards for training and education are keeping pace with developments in health care needs and changing service delivery patterns, in particular the importance of interdisciplinary learning opportunities given the growing importance of team work in the community setting.

What does this mean for the community and health consumers?

Current limitations around training and education of the primary health care workforce are directly impacting workforce supply and communities’ and health consumers’ access to services. For communities, a greater focus on community based training will mean more exposure to students, but also the opportunity for students to be integrated into local communities.

What does this mean for health professionals?

Under current arrangements, the capacity of available teaching practices to accommodate the increasing need for community based clinical placements is limited. For those providing teaching, there is a tension between the need for more teaching places and the potential financial implications of teaching activity. However, there are benefits to being involved in teaching and these can include: enhanced professional development opportunities; increased access to, and the contribution of, registrars; and greater scope to support succession planning.

Where could changes be made?

While governments have implemented various reforms, there continues to be considerable debate about a range of issues regarding education and training models for primary health care training, including the configuration of health workforce courses and course curricula. For GPs, the scope to achieve greater vertical integration of training arrangements has been identified, along with the need to consider enhanced multi-disciplinary approaches. Options for change could consider:

• greater alignment of funding and management of clinical training opportunities between undergraduate, pre-vocational and vocational training to allow the development of more innovative vertical training models;
• greater support for regional training schemes and primary health care clinical training places (particularly in outer metro, rural and remote areas);
• identified support and training opportunities for health professionals who provide education and training to support the provision of high-quality learning;
• exploring models of funding that promote the importance of the teaching role, like part time academic positions and practice based teachers, to increase the status of teaching within the professions themselves;
• supporting innovative learning (eg. simulated learning) and greater e-learning options for busy health professionals;
• how accelerated entry to the workplace could be achieved without comprising quality or standards (eg. fast-tracking or streamlining training);
• increased training, support and development for the role of general practice nurses and nurse practitioners, and further research into the role of nurse practitioners and physician assistants in the primary health care setting;
• how multi-skilled health workers could be supported through an enhanced focus on interdisciplinary learning; and
• how curricula can be expanded to increase focus on chronic disease management, given that primary heath care professionals will spend a greater proportion of time in the future tackling the increasing burden.
  
  
  
  Questions:
  
  • What improvements are needed to primary health care education and training? eg:
  • How can innovative vertically and horizontally integrated teaching models in primary health care be encouraged?
  • How can the role of teaching be better supported in a sustainable way?
  • How could inter-disciplinary learning be better supported and provided in a more sustainable way?
  • Is there a greater role for competency-based education?
  • What incentives could be offered to trainees to make settling in high needs/workforce shortage communities more attractive?

10. Fiscally sustainable, efficient and cost-effective

Objective: All Australians have a primary health care system which is efficient, including making the best use of the available workforce, and is cost effective, fiscally sustainable for governments and affordable for individuals and families.

What happens now?

Health systems that include strong primary health care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes, including lower mortality.^{32, 33, 34} In light of this, many industrialised countries including New Zealand, the United Kingdom and Canada, have undertaken significant investment and reform processes directed at strengthening the primary health care sector.^{35, 36, 37}. In many cases this has included establishing regional health care funding organisations and governance structures that cover primary health care and include significant community input.

Australia’s primary health care system comprises a complex array of programs and services with a variety of financing arrangements. Which services are government subsidised and which are not, and the relative levels of the subsidies involved, are largely a result of historical circumstance rather than rigorous assessment and comprehensive design. At the same time, the evidence to support a robust assessment of cost effectiveness is limited. Different fee levels for services can result in financial, as well as clinical decisions driving practice, or of similar services having differing cost structures depending on the program mechanism. Some services such as those through the MBS are uncapped, such that funding is matched to demand, while others operate with capped budgets. As patients are increasingly needing to see a broader range of health care providers, they are moving between capped and uncapped services more frequently. Where patient contribution is involved, this can depend on location, availability of service options, and workforce considerations, as much as patient capacity to pay.

What does this mean for health professionals?

For the significant proportion of health care professionals who are operating private small businesses and have made a significant investment in infrastructure, it is important that funding arrangements ensure their ongoing financial sustainability. Of course, for those operating small businesses, independence and professional clinical autonomy are also paramount.

Where could changes be made?

Potential changes to primary health care in Australia will need to demonstrate improvements to the effectiveness and sustainability of the health system, with a strong focus on patient outcomes. This could involve examining current allocations of funding and financing arrangements, along with any additional expenditure:

• in the first instance, the imperative is to ensure sensible and cost effective choices around the primary health care services that governments fund directly;
• at the next level, consideration may be about the balance between investment in primary health care compared to other health sectors, particularly acute and aged care services; and
• also a consideration is the balance between government contribution and private including private health insurance contribution in primary health care.

Questions:

• Are there other funding models for primary health care that need to be considered?
• How can we ensure that primary health care expenditure is sustainable?
• Should a new mechanism(s) be implemented to consider whether proposed new primary health care interventions should be subsidised?
• What should be an appropriate mix of public and private funding for primary health care?

References

1. Australian Institute of Health and Welfare, Medicare Australia 2005 Statistics in Australia’s health 2008, Australian Institute of Health and Welfare, Canberra, 2008. Available from: http://www.aihw.gov.au/publications/aus/ah08/ah08.pdf . The Australian Institute of Health and Welfare report states that around 85 per cent of the Australian population sees a GP at least once a year.
2. World Health Organisation (WHO), Declaration of Alma Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 1978. Available from: www.who.int/hpr/NPH/docs/declaration_almaata.pdf . The World Health Organisation’s Alma-Ata declaration of 1978 defined primary health care as: ‘Incorporating curative treatment given by the first contact provider along with promotional, preventive and rehabilitative services provided by multi-disciplinary teams of health-care professionals working collaboratively’.
3. Australian Divisions of General Practice, Primary Health Care Position Statement, Australian Divisions of General Practice, Canberra, 2005. Available from: http://www.agpn.com.au/site/content.cfm?page_id=6675&current_category_code=104&leca=16 . Frequently cited in Australian literature is the definition of comprehensive primary health care developed by the Australian Primary Health Care Research Institute in 2005: ‘primary health care is ‘socially appropriate, universally accessible, scientifically sound, first level care provided by health services and systems with a suitably trained workforce comprised of multidisciplinary teams supported by integrated referral systems in a way that: gives priority to those most in need and addresses health inequalities; maximises community and individual self-reliance, participation and control and; involves collaboration and partnership with other sectors to promote public health. Comprehensive primary health care includes: health promotion; illness prevention; treatment and care of the sick, community development; and advocacy and rehabilitation’.
4. At its 20 December 2007 meeting, the Council of Australian Governments (COAG) established seven working groups, with the Health and Ageing Working Group (HAWG) being one of these. Each working group is overseen by a Commonwealth Minister, with deputies who are nominated by the States and Territories at a senior departmental level. Further information on the HAWG can be found in the COAG Communiques of: 20 December 2007; 26 March 2007; 3 July 2008 and 2 October 2008. Available at http://www.coag.gov.au/coag_meeting_outcomes/archive.cfm
5. On 25 February 2008, the Prime Minister and the Minister for Health and Ageing announced the establishment of the National Health and Hospitals Reform Commission (NHHRC). The NHHRC has been established to develop a long-term health reform plan for a modern Australia. Further information is available from: http://www.nhhrc.org.au/
6. The Hon. Nicola Roxon MP, Minister for Health and Ageing, announced the establishment of the Preventative Health Taskforce (PHT) on 9 April 2008. The Taskforce will provide evidence-based advice to governments and health providers on preventative health programs and strategies, focusing on the burden of chronic disease currently caused by obesity, tobacco and the excessive consumption of alcohol. Further information is available from: http://www.preventativehealth.org.au/
7. A range of issues related to maternity services are being considered by the Maternity Services Review (MSR). Further information on the MSR is available from: http://www.health.gov.au/maternityservicesreview
8. Australian Government Department of Health and Ageing, Medicare Australia Statistics, Australian Government Department of Health and Ageing, Canberra, 2008. Available from: http://www.health.gov.au/medicarestats . In the June 2008 quarter, 79.1 per cent of non-referred GP Medicare services were bulk billed. In the year 2006-07, there were an average of 5.1 GP services per capita.
9. JS Furler, E Harris, P Chondros, PG Powell Davies, MF Harris, DY Young. The inverse care law revisited: impact of disadvantaged location on accessing longer GP consultation times. Med J Aust 2002; 177: 80-83. Available from: http://www.mja.com.au/public/issues/177_02_150702/fur10731_fm.html
10. Eligible Dentists/Dental specialists may provide specific dental care services that attract Medicare benefits under the MBS items 10975 – 10977. The allied health items (10950 to 10970) can only be claimed for services provided by eligible allied health professionals who are registered with Medicare Australia and are delivered by: Aboriginal Health Workers; Audiologists; Chiropractors; Diabetes Educators; Dieticians; Exercise Physiologists; Mental Health Workers; Occupational Therapists; Osteopaths; Physiotherapists; Podiatrists; Psychologists; and Speech Pathologists. Under the Better Access initiative, MBS items provide Medicare benefits for the following allied mental health services:
    • Psychological therapy (items 80000 to 80020) – provided by eligible clinical psychologists; and
    • Focussed psychological strategies – allied mental health (items 80100 to 80170) – provided by eligible psychologists, occupational therapists and social workers.
11. The Commonwealth Fund, International Health Policy Survey in Seven Countries, The Commonwealth Fund, New York, 2007. Available from: http://www.commonwealthfund. /surveys/surveys_show.htm?doc_id=568326. Eighty seven per cent of Australian respondents sampled reported receiving excellent or very good quality of care from their family doctor.
12. Institute for Healthcare Improvement, Patient-Centred Care General, Institute for Healthcare Improvement website, Massachusetts, United States of America, 2008. Available from: http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/
13. Australian Bureau of Statistics, Health Literacy, Australia, 2006, Catalogue No. 4233.0, Australian Bureau of Statistics, Canberra, 2006. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4233.0Explanatory%20Notes12006?OpenDocument . This report shows that 59 per cent of the Australian population aged 15 to 74 years did not achieve health literacy skill level 3 (out of 5) or above, which is the minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy.
14. Australian Commission on Safety and Quality in Healthcare, Development of a Consumer Engagement Strategy for the Commission: Background Paper, Australian Commission on Safety and Quality in Healthcare, Sydney, July 2008. Available from: http://www.safetyandquality.org/internet/safety/publishing.nsf/content/0EE542BF224D4227CA2574890019A935/$File/Final-CES-Paper-3Sep2008.pdf
15. Royal Australian College of General Practitioners, Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting, 2nd edn, Royal Australian College of General Practitioners ‘Green Book’ Project Advisory Committee, Melbourne, 2006, pp. 8 . Available from: http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheGreenBook/RACGPgreenbook2nd.pdf
16. DW Dunstan, PZ Zimmet, TA Welborn, MP De Courtan, AJ Cameron, RA Sicree et al, on behalf of the AusDiab Steering Committee, ‘The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity and Lifestyle Study’, Diabetes Care, vol. 25, 2002, pp. 829 – 834. Available from: http://care.diabetesjournals.org/cgi/reprint/25/5/829
17. PO Frith, Prevalence and Treatment of Chronic Obstructive Pulmonary Disease (COPD) in Australia Final Report, The Australian Lung Foundation, Queensland, November 2004. Available from: http://www.copdx.org.au/resources/documents/lung_health_sur_2004Nov.pdf
18. Australian Institute for Health and Welfare, Australia’s health 2008, Australian Institute of Health and Welfare, Canberra, 2008. Available from: http://www.aihw.gov.au/publications/aus/ah08/ah08.pdf
19. MF Harris & NA Zwar, ‘Care of patients with chronic disease: the challenge for general practice', Medical Journal of Australia, vol. 187:2, 2007, pp. 104 – 107. Available from: http://www.mja.com.au/public/issues/187_02_160707/har10436_fm.html
20. Australian Bureau of Statistics, National Health Survey: Summary of Results 2004-05, Australian Bureau of Statistics, Canberra, 2006. Available from: http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/3B1917236618A042CA25711F00185526/$File/43640_2004-05.pdf More recent data from Australia’s health 2008 indicates that people with lower socioeconomic status and those also living outside major cities, are more likely to smoke, exercise less, be overweight and/or obese and have fewer or no daily serves of fruit and vegetables – all of which are key risk factors for chronic disease.
21. National Health and Hospital Reform Commission, Beyond the Blame Game: Accountability and performance benchmarks for the next Australian Health Care Agreements, Australian Government Department of Health and Ageing, Canberra, April 2008. Available from: http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/504AD1E61C23F15ECA2574430000E2B4/$File/BeyondTheBlameGame.pdf
22. Results from The Commonwealth Fund surveys of 2004 (Commonwealth Fund International Health Policy Survey of Adults' Experiences with Primary Care), 2005 (Commonwealth Fund International Health Policy Survey of Sicker Adults) and 2007 (International Health Policy Survey in Seven Countries) had Australian respondents reporting high incidences of medication or lab errors, ordering of duplicate tests, and receiving conflicting information from health professionals. Available from: http://www.commonwealthfund.org/surveys/surveys_list.htm
23. Australian Institute for Health and Welfare, Australia’s health 2008, Australian Institute for Health and Welfare, Canberra, 2008. Available from: http://www.aihw.gov.au/publications/aus/ah08/ah08.pdf Since practices must be accredited or registered for accreditation to join the Practice Incentives Program (PIP), data from this program are broadly representative of the number of accredited practices. In May 2006, there were 4,745 practices participating in the PIP. PIP practices provided 85.2 million GP services during 2005–06. The proportion of GP services provided by practices participating in the PIP was 80 per cent for Australia in 2005–06.
24. JJ Yallop, BR McAvoy, JL Croucher, A Tonkin and L Piterman on behalf of the CHAT Study Group, ‘Primary health care research – essential but disadvantaged’, Medical Journal of Australia, vol. 185:2, 2006, pp. 118-120. Available from: http://www.mja.com.au/public/issues/185_02_170706/yal10357_fm.html
25. HC Britt, CM Harrison, GC Miller, and SA Knox, 'Prevalence and patterns of multimorbidity in Australia', Medical Journal of Australia, vol. 189:2, 2008, pp. 72-77. Available from: http://www.mja.com.au/public/issues/189_02_210708/bri10473_fm.html. Multi-morbidity is a term that is being increasingly used within health care and is understood to mean: ‘the co-occurrence of two or more diseases within one person without defining an index-disease
26. Australian Government Department of Health and Ageing, IT Readiness Survey of the Aged Care Sector, 2006: Summary of Findings, Australian Government Department of Health and Ageing, Canberra, 2006. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/23D4B48C3B08BC0ECA2570FF000FA773/$File/itsurvey06.pdf
27. MF Harris & NA Zwar, ‘Care of patients with chronic disease: the challenge for general practice’, Medical Journal of Australia, vol. 187:2, 2007, pp. 104-107. Available from: http://www.mja.com.au/public/issues/187_02_160707/har10436_fm.pdf
28. H Britt, GC Miller, J Charles, J Henderson, C Bayram, C Harrison, L Valenti, S Fahridin, Y Pan, J O’Halloran, General practice activity in Australia 1998-99 to 2007–08: 10 year data tables, General practice series no. 22, Australian Institute of Health and Welfare, Canberra, October 2008. Available from: http://www.aihw.gov.au/publications/gep/gpaia98-99-07-08-10ydt/gpaia98-99-07-08-10ydt.pdf
29. J Wakerman, EM Chalmers, JS Humphreys, CL Clarence, AI Bell, A Larson et al, ‘Sustainable chronic disease management in remote Australia’, Medical Journal of Australia, vol. 183 (10 Suppl), 2005, pp. S64-68. Available from: http://www.mja.com.au/public/issues/183_10_211105/wak10600_fm.pdf
30. Australian Government Department of Health and Ageing, Report on the Audit of Health Workforce in Rural and Regional Australia, Australian Government Department of Health and Ageing, Canberra, April 2008. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/work-res-ruraud. The primary medical workforce growth from 2001 to 2005 was only 4.2% (compared to 12.9% of the total medical workforce) and this was less than the growth of the Australian population over the same period.
31. Data has been sourced from General Practice Education and Training Ltd.
32. G Browne, J Robert, A Gafni, C Byrne, R Weir, B Majumdar, S Watt et al, ‘Economic evaluations of community-based care: lessons from twelve studies in Ontario’, Journal of Evaluation in Clinical Practice, vol. 5, 1999, pp. 367-385. Available from: http://www3.interscience.wiley.com/journal/119089666/abstract
33. CB Forrest & EM Whelan, ‘Primary care safety-net delivery sites in the United States: a comparison of community health centres, hospital outpatient departments, and physician’s offices’, Journal of the American Medical Association, vol. 284, 2000, pp. 2077-2083. Available from: http://jama.ama-assn.org/cgi/reprint/284/16/2077?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Forrest+C%2C+Whelan+EM&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
34. B Starfield, ‘Is Strong Primary Care Good for Health Outcomes?’ in J Griffin, ed., The Future of Primary Care: Papers for a Symposium held on 13th September 1995, Office of Health Economics, London, 1996, pp. 18–29.
35. United Kingdom Parliament. National Health Service (Primary Care) Act 1997, ch 46. United Kingdom Parliament, London, 1997. Available from: http://www.opsi.gov.uk/Acts/acts1997/ukpga_19970046_en_1
36. B Howell, ‘Restructuring primary health care markets in New Zealand: from welfare benefits to insurance markets’, Australian and New Zealand Health Policy, vol. 2:20, 2005. Available from: http://www.anzhealthpolicy.com/content/pdf/1743-8462-2-20.pdf
37. RJ Romanow, Final report of the Commission on the Future of Health Care in Canada, Canadian Government Publishing, Ottawa, 2002. Available from: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/hhr/romanow-eng.pdf