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

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.

It’s not just the My Health Record we should be concerned about

It’s often been said, the Australian My Health Record is not a finished project. It is evolving and has, indeed, lots of potential to improve and streamline patient care. Sadly, the privacy issues that have haunted the project for years still seem to be unresolved. And when it comes to secondary use of patient data, there’s more to come from a different direction.

Back in 2013 I wrote this in a blog post about the My Health Record, then called the Personally Controlled Electronic Health Record or PCEHR:

“The PCEHR Act 2012 states that the data in the PCEHR can be used for law enforcement purposes, indemnity insurance purposes for health care providers, research, public health purposes and ‘other purposes authorised by law’. This is far from reassuring. There are many grey areas and unanswered questions. There are too many agendas. The PCEHR should first be a useful clinical tool to improve patient care.”

Five years later and there are still ambiguities about when, how and for what reason law enforcement agencies and other non-medical parties can access the national My Health Record system. This should have been crystal clear by now. Here’s is what I posted in 2015:

“(…) at the moment the information in the PCEHR may be used by the Government for data mining, law enforcement purposes and ‘other purposes authorised by law’, for up to 130 years, even after a patient or provider has opted out. (…) The legal framework should be reviewed, and any changes must be agreed upon by consumers and clinicians.”

When asked about this issue at yesterday’s Press Club AMA president Dr Tony Bartone indicated that he is prepared to push for legislative amendments to improve the confidence of Australians in the My Health Record.

I was glad to hear this. I’m all for amendments of the My Health Record legislation but at the same time the Department of Health is on a journey to get its hands on GP patient data – and this is unlikely to change.

For example, the Department of Health is preparing a new data extraction scheme, to be introduced in May 2019. To remain eligible for practice incentive payments GP clinics have to agree that de-identified patient data will be extracted from their clinical software by, perhaps, Primary Health Networks. From there the data may flow to, possibly, the Australian Institute of Health and Welfare, the organisation responsible for the secondary use of data in the My Health Record.

If this scheme goes ahead, government organisations will begin to take over data and quality control of general practice. The argument will be that it is in the interest of the health of the nation. Perhaps it’s my well-worn tin foil hat, but I have a sneaking suspicion what I will be blogging about in the years to come.

Why we need to get over the Medicare Locals disappointment

Many people are still getting over the disappointment of Medicare Locals. I get that. Although some MLs were able to make a difference, too many were not. The new Primary Health Networks (PHNs) may be a different kettle of fish. One thing is for sure: they are here for the long haul.

There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community. For that reason the RACGP is keen to work with the new organisations. I believe there are at least three areas where grassroots support from local PHNs can make a big difference.

Working together

The first area is relationship building and teamwork. We all know there are too many silos and tribes in healthcare. On the other hand, long-term relationships positively influence knowledge exchange, understanding and trust.

Where possible, health providers should be freed up to have the option to discuss clinical care with each other. This is important all for health professionals, and even more so for those working in rural and remote areas.

We should ensure that non-clinicians do not get in the way of effective inter-collegial communication. For example, referral letters have to contain the necessary information to allow the next health provider to do their job properly, but we must avoid overly bureaucratic referral rules. A clinical override mechanism of these rules must always be available.

PHNs could assist, for example, with developing shared clinical priorities and organising site visits, breakfasts, lunches, dinners and conferences that cross disciplinary and organisational boundaries.

Continuity of care

The second area is improving continuity of care. This is not a catchphrase, but a crucial element of general practice with numerous proven long-term health benefits. Unfortunately it seems this principle is often sacrificed in new initiatives and models for the sake of short-term results, convenience or commercial interests.

It is helpful to distinguish the three types of continuity of care, as explained by Haggerty et al: informational continuity (sharing data), management continuity (sharing a consistent approach) and relational continuity (fostering an ongoing therapeutic relationship).

Electronic health records will assist with informational continuity, but not necessarily with management continuity and relational continuity.

“New models of care should not further fragment care

There is ample evidence that comprehensive, continuous care by GPs results in improved patient health outcomes and satisfaction. Continuity of care is cost-effective and reduces both elective and emergency hospital admissions.

GPs play a key role in keeping people out of hospital. It is important however that hospital avoidance projects help to build capacity, facilitate access in primary care and respect the principle of continuity of care.

New integrated models of care should carefully be evaluated to make sure they don’t do the opposite and fragment care thereby negatively impacting on health outcomes – often with the best intentions. PHNs can play a big role here.

Data exchange and communication 

A third area where PHNs should assist general practice is electronic data exchange and communication. Because of its central position in primary care, general practice is the natural collection point of clinical information. Direct, secure, electronic communication between GPs, specialists, community pharmacists and allied health providers is beneficial for optimal patient care, but remains problematic in many regions.

“Delayed information from hospitals is still one of the biggest problems

Delayed or absent correspondence from hospitals to referring doctors is still one of the biggest problems for GPs who are frequently trying to deal with returning patients without any information from the hospital.

All necessary information should be supplied in hospital discharge summaries, and it should not be left to the GP or practice staff to chase up any information from the hospital.

General practitioners need to ensure their referrals are of sufficient quality, consistent with RACGP standards, and useful for practitioners who continue the patient care in different settings of the health system. That means the referral information must be complete, accurate and timely.

Hospital referral criteria may require additional, locally agreed-on information, but extensive extra information (such as patient questionnaires) is the responsibility of the requesting institutions, and GPs should not be made responsible for its collection and supply.

There is room for improvement of communication between GPs. Getting the different healthcare computer systems to talk to each other is a big issue in many parts of the country. This is problematic as Australia has a mobile population. Low-cost software solutions such as GP2GP, used in New Zealand and the UK, could solve this.

The MyHealthRecord (formerly PCEHR) is, due to its many technical and medicolegal issues, not yet widely accepted as a reliable clinical tool and we see more alternative, locally developed e-health solutions in the near future.

In conclusion there are substantial opportunities for PHNs in supporting and adequately resourcing general practice and its interactions with other parts of the health system. To quote the National Health and Hospitals Reform Commission (NHHRC): “We believe that strengthened primary health care services in the community, building on the vital role of general practice, should be the ‘first contact’ for providing care for most health needs of Australian people.”

This article was originally published in The Medical Republic.