WANTED: shared vision for primary care

“I do know that when primary care doesn’t connect, collaborate and work together – patients see and feel that disconnection. And I have a feeling that those working in primary care see and feel it too.

Belinda MacLeod-Smith, health consumer (BridgeBuilders.vision)

Labor’s health spokeswoman Catherine King announced that her party will create a permanent health reform commission if it wins the federal election. I thought this sounds like a step in the right direction as long-term planning of health reform is much needed in Australia.

On the other hand, there have been many government committees, task forces, reviews and reports that haven’t made a dent in the primary care landscape.

If only we could put together some of the ideas coming from Australia’s health and consumer groups. These organisations, often working at the coal face of primary care, have an excellent understanding of the urgent needs and requirements. 

I was pleased to see that some of this year’s pre-budget submissions by primary care organisations contain similar ideas. For example, the pre-budget submissions from AMA, ACRRM and RACGP all argue for funded telehealth services.

As expected, there is a strong push for adequate patient Medicare rebates and reduced patient out-of-pocket costs. The general practice profession also believes that spending more quality time with patients should be encouraged through better remuneration of longer consultations. 

One of the main themes is improving care for people living with chronic and complex conditions. The Australian Medical Association is proposing a chronic disease quarterly care coordination payment to GPs to support team-based care. 

The Royal Australian College of General Practitioners is advocating for comprehensive reform that includes blended funding, based on the Vision for general practice and a sustainable healthcare system.

The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiative to support people with chronic conditions to actively manage their own health.

Rural doctors, RDAA and ACRRM, are asking for more junior doctor training places in rural and remote settings and a move to the rollout phase of the National Rural Generalist Pathway.

This is just a selection of some of the budget submissions. What struck me is that there is a lot of merit in many of the proposals. They are often not mutually exclusive.

Unfortunately, most budget submissions seem to end up in a large pile on the minister’s desk. Many great ideas never see the light of day, because there is no sector-driven vision or strategy.

Is this the best we can do? I believe it is time to work towards a shared vision for primary care. Why not start by looking at what the various organisations and groups have in common?

Is value based healthcare devaluing care?

There’s a lot to say for high value care. High value care is healthcare that generates a large amount of benefit for patients and the community compared to the resources invested. But there are also concerns.

Value based healthcare links outcomes with costs: ‘Value’ is derived from measuring health outcomes against the cost of delivering these outcomes. Although it makes sense to fund care that gives us the greatest health benefits, some argue that ‘value’ is more than outcomes.

Dr Jan Kremer is a Dutch Professor in patient-centred innovation and has a passion for patient-focused quality and innovation. In a recent blog post he questioned value based healthcare, stating that value has a different meaning to different people – ranging from efficiency to solidarity, equity and quality of life.

The right things

In healthcare, he said, it is not just about doing things right, but also about doing the right things. The former can be measured, the latter is about decision-making which can’t always be quantified. After all, we can achieve the desired outcomes by doing the wrong thing.

Indeed, a focus on outcomes only tells part of the story. Care may have value for people even when the outcomes are not good.

It is impossible to capture the complexity of healthcare through linear mechanical quality systems, like measuring isolated single-disease parameters. As Goodhart’s law says: ‘When a measure becomes a target, it ceases to be a good measure’.

Models that focus on outcomes often result in only modest improvements, usually not long-lasting and sometimes reducing quality of care for health conditions that are not targeted.

These models can negatively affect the patient-doctor relationship and take away the passion and enthusiasm of care providers.

Learning together

Everyone wants value in healthcare. Professor Kremer said we must be careful with anglo-saxon models that measure everything. But there are alternatives.

In the Netherlands, learning together based on shared values, and measuring less, has resulted in important successes. According to Professor Kremer outcome data has been helpful in the development of Dutch high value care models, but it never controlled the process.