Has Australian general practice moved one step closer to the British NHS?

Has Australian general practice moved one step closer to the British National Health Service?

In 2019, the Department of Health, via its practice incentive scheme, will not only start setting the key performance indicators of general practice but also further tighten its grip on practice data. It is not unlikely that the Department’s strategy will create the same issues the National Health Service is currently encountering: loss of patient-centeredness of care, unreasonable KPIs and low doctor morale.

The redesign of the Practice Incentive Program (PIP) has been in the cards for a while. The introduction of a new quality improvement (QI) payment system was deferred for 12 months in May 2018 because of concerns that it was not fit for purpose.

Central role of PHNs

If it goes ahead in May 2019, the impact of the new scheme will be significant. The big change will likely be that Primary Health Networks (PHNs) become exclusive “QI providers” for general practice. This means that they will extract, analyse and store practice data and present GPs with benchmark reports. Many PHNs have already started collecting data in anticipation of the changes.

To be eligible for quality improvement incentive payments, practices will have to demonstrate to PHNs that their performance is on par with the Department’s KPIs. Although analysis and benchmarking of clinical data are becoming increasingly important to improve patient care, there are many issues with the proposed PIP overhaul.

Initially, there was talk about more organisations becoming QI providers, such as the Royal Australian College of General Practitioners (RACGP) and the Improvement Foundation, but, according to Medical Observer, it looks like there will be no profession-led alternative to the PHN model and, as a result, practices will not be given a choice of QI providers.

General practice is at risk of gradually losing control over its quality improvement processes, which will no doubt leave many grassroots GPs dismayed.

Professional buy-in?

The main issue with the scheme is related to professional buy-in. The Department of Health has gone through the usual process of consulting the profession, but it has always been clear that the PIP redesign was going to occur regardless of the opinion of GP groups.

The Department may claim in its communications that the KPIs are supported by the various professional bodies, but the level of engagement, trust and satisfaction with the new QI system will be low for various reasons.

First, this is an example of a top-down government solution, largely designed by the Department of Health. As we have seen with the My Health Record and Health Care Homes, this approach usually creates just as many problems as it is trying to fix.

Similarly, there has been a lack of engagement with the e-health PIP (ePIP) scheme, which requires practices to upload shared health summaries to the My Health Record to remain eligible for incentive payments or ePIP. This may have given the Department a countable number of uploads, but there is no evidence to suggest that it has improved meaningful use of the My Health Record or quality of care in general practice.

Weak evidence

In the PIP redesign process, only payments to practices have survived. For example, the aged care incentive payment to GPs providing care to patients in residential aged care facilities will be scrapped. This incentive is worth $3000–$5000 per doctor. Many have argued that it is incomprehensible that funding benefitting aged care is removed at a time when residential aged care facilities need more support to provide the medical care required.

By stopping these service payments to individual doctors, the incentives will be one step further removed from those who are responsible for the actual quality improvement activities. Again, this does not inspire confidence in the Department’s new QI system.

Measuring performance against KPIs in combination with performance payments will almost certainly create new problems. Quality indicators used by governments around the world are often easy to measure isolated parameters that have limited valuefor complex systems such as general practice.

The evidence to support financial incentives is weak, and the British Quality and Outcomes Framework (QOF) pay-for-performance system has illustrated what can go wrong: QOF has not improved care but did result in the loss of the patient-centredness of care and has created a significant decrease in doctor morale.

No funding priority

The new QI PIP will be subsidised by a shift of funding from other PIP and SIP incentives — which has been labeled as “robbing Peter to pay Paul” by the Australian Medical Association. In 2016, $21 million were removed from the PIP budget to partially fund the Health Care Home trials. The last budget announcements made it clear that there will be no increase in PIP funding in the near future. The PIP scheme, introduced in the 1990s, has never been indexed.

The Department of Health has not yet provided clarity on what the PIP scheme will look like beyond May 2019. This lack of transparency about long term planning creates uncertainty for practices. Although the expectations will start off low, it is to be expected that the Department will adjust the KPIs upwards over time, wanting more for less.

One of the PIP eligibility criteria for practices is accreditation against the RACGP’s Standards for general practices, and it will be interesting to see if upcoming changes to the PIP scheme will affect the percentage of practices that take the effort to go through the accreditation process.

Data extraction

Finally, general practice is not only facing loss of control of quality improvement but is also about to miss out on an opportunity to become custodians of its clinical data. Although the QI PIP data will be extracted from GP practices, it will likely be managed and controlled by PHNs and other government agencies, such as the Australian Institute of Health and Welfare.

When the government defunded the Bettering the Evaluation and Care of Health (BEACH) study in 2016, general practice lost its most important longitudinal source of data. It doesn’t take much imagination to figure out what will happen with the QI PIP data when, in a future reform cycle, PHNs or other government agencies involved are subject to funding cuts or cease to exist altogether.

The Department of Health’s underlying thinking seems to be that the responsibility for quality and data should be taken away from the profession, even though the government’s own data governance practices don’t always inspire confidence.

Professional response

The department should have given professional organisations the responsibility to execute a mutually agreed strategy, acceptable to all parties, including custodianship of data for quality improvement purposes.

Our peak bodies are working hard behind the scenes to negotiate the best possible outcome. It is more important than ever for the profession to work through any differences and present a united front. The question remains, can we stem the tide of increasing departmental control or has general practice definitely moved one step closer to the NHS?

This article was originally published in MJA Insight.

10 thoughts on “Has Australian general practice moved one step closer to the British NHS?

    • Yes it has indeed Karen and I expect the targets will be easy to reach initially. The temptation will be to agree & sign up to remain eligible for the practice incentive payments. Quality improvement based on data analysis should become the norm but not at the expense of professional autonomy & responsibility.

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  1. Thanks for another great article Edwin. So this QI PIP replaces the following five incentives which were to cease on 1 May 2018 but will continue through to 30 April 2019.

    The five incentives are:

    Asthma Incentive
    Quality Prescribing Incentive
    Cervical Screening Incentive
    Diabetes Incentive, and
    General Practitioner Aged Care Access Incentive.

    These are mainly SIP payments with some pretty minor practice payments.

    This looks like a fairly minor payment for private data from GP practices. It’s an opt in system – how many practices may say no?

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  2. Excellent commentary as usual Edwin!
    Because I do RACF care, my income is about 15% less than my colleagues at my practice: and now loss of PIP aged care incentive in 2019….
    Who will provide this vital service in future?

    Re data issues: AMA RACGP and ACRRM all have to be united in their position:
    GPS themselves have to take ownership and UNDERSTAND the implications for our patients and profession
    Medicare freezes, loss of PIPs, loss of autonomy…

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    • Thanks Frank, the decision to scrap the aged care incentive payments for GPs who take the effort to visit nursing home residents was indeed not one of the department’s finest moments. Let’s hope for a suitable MBS alternative (and pray for professional unity….)

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  3. Great article as usual.

    The AgedCare issue is very topical at present and loss of that PIP component will definitely lead to a further exodus of GPs attending RACFs.

    I do note that the Health of the Nation 2018 report states that 15% of GPs still attend RACFs – I suspect that is a huge over estimation (as is the claim that 22% of GPs are Practice Owners) and unfortunately a likely reflection of the very large selection bias in the research used for those stats.

    The reality is that a tiny minority of GPs are still attending RACFs and the numbers are shrinking by the day

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  4. Great article Edwin. I will rewrite it and claim it as my own. 😉

    I have some questions. Some are rhetorical.

    What will be the time frame for the release of the details about the new scheme?
    Do we know what data is being uploaded?
    Is the data uploaded from the PHNs to the Feds?
    Are the KPIs known?
    Are their KPIs for the PHNs?
    Are patients permitted to exempt their own “deidentified” data from upload?
    Are GPs permitted to exempt intransigent patients from the upload statics?
    Is comprehensiveness of care to be measured? e.g. The practice has to provide nursing home care.
    Will the AMA or RACGP be permitted access to the aggregated data as representatives of the profession?
    Does the Labor Party endorse this initiative?

    The Federal election is due before the end of May.

    So many questions. Such little time.

    David

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