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.

How should Primary Health Networks support GPs?

It appears the new  Primary Health Networks (PHNs) are here to for the long haul. There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community.

RACGP Queensland has developed a draft position statement identifying 4 concrete targets that should be aimed for in primary healthcare reform at a local level.

The targets are presented below. I believe that PHNs could play an important role in achieving these goals – in collaboration with GPs.

  1. PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.
  2. PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.
  3. PHNs need to play an important role in facilitating better information exchange and communication between healthcare providers.
  4. PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.

Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.

What health consumers want: interview with Leanne Wells

Generating consumer-led ideas to improve the health system – that’s what the Consumer Health Forum is all about, says new CEO Leanne Wells. Health consumerism around the world is changing, and Leanne sees a potential for big reforms in Australia. I asked her about a range of topics, including the Medicare rebate freeze, the RACGP draft vision for a sustainable health system, funding and the role of pharmacists.

“It is a terrific honour and challenge to be leading this organisation at a time of significant developments in the role of health consumerism globally,” she says. “I believe in a strong patient-clinician alliance.”

“Consumer leadership is as important as clinical leadership in developing modern health systems that reflect the importance of patient-centred care. We can achieve this by working together to influence policy settings, design and operation of health care.”

Consumer-led ideas

What health consumers want: intervie with Leanne Wells
Leanne Wells: “Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity.”

“Our members include a diverse range of consumer organisations as well as professional associations, researchers and individuals with an interest in health consumer affairs. Through our membership network, we reach millions of Australian consumers.”

“CHF is all about generating consumer-led ideas for a better health system. It is the pre-eminent national organisation advocating on behalf of health consumers on policy issues pertaining to Medicare, PBS and population health and on issues such as health system development, access to best available consumer-centred care and access to medications.

“CHF’s work has included research and national campaigns on rising out-of-pocket health costs and prescription medicine costs. We deal frequently with questions from media on issues such as health insurance and quality and safety in health care.”

“There is potential for significant changes in Australia’s health system, particularly in Commonwealth-financed areas such as Medicare, primary health care and mental health, at a time when there are moves to put focus on reforms to Commonwealth-State health funding issues. In all of these areas, consumer-generated ideas for a better system will be crucial to success.”

Medicare rebate freeze

“CHF has supported the RACGP and others in the campaign against the rebate freeze. Nothing should compromise good quality, comprehensive, co-ordinated patient care. I support the concept of the patient-centred healthcare home.”

“Some consumers have capacity to pay a co-payment and will do so if they feel they get value. Others simply won’t go to the doctor if they are not bulk billed – and often those who don’t go to the doctor due to cost barriers are those from lower socioeconomic circumstances which we know are associated with higher rates of complex, chronic conditions: the very conditions that need ongoing, co-ordinated care. The issue highlights the need for the MBS review and a rethink of the way we finance primary care. Both are long overdue.”

“General practices need the flexibility to be truly responsive to their patient populations

“CHF seeks funding that is determined by the right models of care, not the other way around. At the moment we’ve got a system that is largely based on fee-for-service financing to drive and, at times, limit models of care.”

“General practices need the flexibility to be truly responsive to their patient populations. The expansion of health insurance to primary practice, may offer benefits in terms of better integrated care for some. The overall impact however is likely to be negative, setting up a two-tiered health system at the primary care level where insured patients would be likely to get preferential treatment.”

“The RACGP’s draft consultation paper ‘Vision for a sustainable health system’ makes the case for an alternative blended payment model offering flexibility and autonomy to respond better to contemporary care needs. The paper would be stronger if it articulated a vision for general practice emphasising how that could be done.”

“The paper lacked consideration of aspects of integrated care and placed ‘general practice’ rather than ‘the patient’ at the centre of the health system. We would have liked the paper to place greater emphasis on the patient as partner and on the consumer benefits of team-based care as well as the other non-financial levers that can work in concert to bring about change and innovation in general practice.”

Consumers as partners

“A big challenge is for health care to be much more consumer-centred. That works best when there’s a team of professionals looking after the consumer, when there’s an open flow of information and discussion between them about the patient’s needs and how to meet them together rather than separately.”

“We want to see a patient-centred approach to providing care – not disease-centred or system-centred

“Above all else patients want professionals who see them as more than just the ‘vessel’ of a disease to be cured, or a problem to be solved. Patients want to be recognised for who they are: unique individuals with their own unique lives. We want to see a health workforce which takes a patient-centred approach to providing care – not disease-centred, not system-centred, but patient-centred.”

“The National Safety and Quality Health Service Standards have consumers as partners in care as its second standard – solid recognition that this value must become inherent to the culture and operation of health services. Primary Health Networks have a pivotal role in bringing this about.”

“Having worked with divisions of general practice and Medicare Locals since the 2000s, I remain a strong proponent of the place ‘meso’ structures like these have in the system. The Primary Health Networks have great promise as disruptive innovators in our system.”

“With their distinct boundaries, alignment with hospital networks, relationship with general practice and the knowledge they will grow about their local communities, they are well placed to work with patients and clinicians to lead service and system development and innovation.”

“But they can only do this if they have mandate, the support and participation of patients and clinicians and the financial flexibility to invest in new approaches and new models of care.”

Dysfunctional state-federal funding

“The CHF supports a single level of government taking responsibility for leadership in health policy. We are diverse country with distinct regional communities. I believe moving to a single level of government, with regional purchasers administering pooled funding, is a concept worth exploring further.”

“The only way we are going to integrate the system is by having policy set nationally, and service commissioning undertaken regionally by single entities. Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity. Removing the dysfunctional nature of state-federal funding would surely be an improvement on what we have now.”

Devaluation of general practice

“Patients need to be seen as partners in care – assets not deficits. I agree that general practice and its place in the health system has become devalued over time. It is a very efficient and effective setting in which to deliver care close to where consumers live and work.”

“I applaud the RACGP’s efforts to get general practice better recognised and valued

“I applaud the RACGP’s efforts to get general practice better recognised and valued. However, in the campaign video, the doctor is represented as the sage authority while the patients are represented as passive recipients of the doctor’s view of them and their lives.”

“The characterisation was at odds with all the evidence showing that approaches which encourage patient-centred and patient-engaged care produce better outcomes. This aspect of the doctor-patient relationship could have been better reflected.”

Pharmacists and General Practice

“CHF supports a stronger role for pharmacists in general practice in areas such as medication support. It would be in the patient’s interest for general practice to have non-dispensing pharmacists as part of the team available to advise on quality use of medicines, hopefully freeing up GPs to focus on time-consuming, complex cases requiring medical expertise.”

“Expanding the scope for dispensing pharmacists to provide medical advice in pharmacies would also be supported by CHF provided the role was strictly within the pharmacist’s qualifications, was coordinated with the patient’s GP or local GP and where necessary, the services performed in a private area. Both options are good ways to make better use of an existing valued workforce.”

Patients or consumers?

“There is a continuing debate on the patient-consumer dichotomy. We prefer the use of the word ‘consumer’ when talking in terms of the health system generally. In that context we think the word consumer more accurately expresses the non-dependent status of a citizen and customer of health services and products.”

“The word ‘patient’ is appropriate when referring to an individual under treatment of a clinician where the patient’s outcome is directly dependent on the clinician.”