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?

Our story, our vision – the future of general practice

We now have an excellent vision for a sustainable Australian healthcare system and general practice.

The final version of the vision was released by RACGP president Dr Frank Jones at the GP15 conference in Melbourne this week. It is based on feedback from over 1,000 GPs, stakeholders and consumer groups.

There are 2 elements of the vision that make it remarkable:

#1: the medical home

A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes. The medical home encourages voluntary patient registration with a preferred practice. It will benefit patients and doctors as it allows for continuity of care and effective, better-targeted coordination of care to meet patient needs.

Patients may choose whether to enrol with a practice of their choice. Likewise, GPs and practices may choose to take part in the program.

Patients will be able to visit any general practice for standard care, but chronic disease management, integration of care and preventive health will be limited to their medical home.

#2: a new funding model

The RACGP proposes a major overhaul of the current funding system. It’s a flexible model and includes support for GPs and their teams to deliver multidisciplinary teamwork and coordination work on behalf of their patients.

A comprehensiveness payment made to a practice would recognise the practices and practitioners that provide a broad range of services to the community.

The current PIP and SIP regimes need to be replaced by practitioner support and practice support payments as outlined in detail in the vision document.

The story of general practice is told in this new RACGP video, spoken by Sigrid Thornton.

An opportunity for the Government to develop a real health policy

“Health policy has proved, over the years, to be a bugbear for the Liberal Party. The Fraser Government had made numerous changes to its health policy, which had been both unsettling and politically damaging” ~ John Howard in Lazarus Rising

As they say, those who cannot remember the past are doomed to repeat it. Governments often make two mistakes when it comes to health policies:

  1. It is driven by dollars instead of health outcomes
  2. Advice from patients and health professionals is ignored

The current ‘health’ debate has, in reality, been a debate about the level of out-of-pocket expenses. The elephant in the room – more efficient funding – has been carefully avoided. We know there is too much waste and bureaucracy in the system – and many have argued the fee-for-service model is not ideal to manage chronic health problems.

If the Abbott Government is serious about tackling some of these issues, but wants to avoid the mistakes of the past, they should embrace the RACGP’s draft Vision for a sustainable health system. It is an opportunity to start a real healthcare debate.

The new model

As the draft document reiterates, health systems focusing on primary healthcare have lower use of hospitals and better health outcomes when compared to systems that focus on specialist care. It makes sense to fund a comprehensive range of services in primary care, based on local community needs.

The new vision proposes voluntary patient enrolment with a preferred practice to improve chronic care delivery and funding. It also recommends that current incentive payments are replaced by a payment system that facilitates the following five key activities:

  1. Better integration of care
  2. Supporting quality, safety and research
  3. Team-based nursing care
  4. Using IT and e-health to improve efficiency
  5. Teaching students

Acute care and fee-for-service are still part of the package, but practices and GPs delivering ongoing comprehensive and complex care will be better rewarded in the new model. It will also assist practices and doctors looking after disadvantaged patient populations.

Much needed leadership

Earlier this year the RACGP invited members to comment on a first draft. Yesterday RACGP president Frank Jones presented the current version to Federal Health Minister Sussan Ley. It’s good to see the RACGP welcomes further feedback. Personally I am particularly interested in the response from patients and consumer organisations.

It seems the blended payment model reflects the increasing focus on chronic disease management, while still rewarding acute care. As always, the devil will be in the detail. But to be fair, this is a draft (and if you ask me, a good one).

By starting the discussion the RACGP is showing leadership. Let’s hope the Federal Health Minister is appreciative and brave enough to take on the challenge.

Revised payment model
Revised payment model as suggested by the RACGP: The model blends fee-for-service with practitioner support and practice support payments. Source: RACGP