Introduction by Croakey: The debate on primary healthcare in Australia is often limited to access – or a lack thereof – to GPs. But as a recent report suggests, there is much more to assessing the performance of a country’s primary healthcare system than how many patients can get through the door (or see their GP on a screen).
Issues such as having a long-term GP, coordination of care, and even dealing with the bureaucracy all matter in terms of effective delivery and better patient outcomes.
Charles Maskell-Knight writes:
It is always interesting to see ourselves as others see us. International comparative studies of healthcare systems often offer fresh insights into how Australia’s system performs.
The recent Commonwealth Fund report, Finger on the pulse: the state of primary care in the US and nine other countries, is a good example.
All too often public discussions about primary care in Australia are reduced to an argument about financial barriers to access GPs and the validity of different metrics: the proportion of all services that are bulk-billed, the proportion of practices that bulk-bill every patient, the proportion of people that are always bulk-billed, and so on.
Of course, access to primary care is important. But how well the system performs after a patient has accessed it also matters, and the Commonwealth Fund report offers interesting perspectives on some of these issues.
Data sources
Unlike many OECD reports, which rely on data collected by national governments and are often inconsistent at the margins, the Commonwealth Fund report is based on original data collections it commissioned. These are:
- A 2022 International Health Policy Survey of Primary Care Physicians administered to nationally representative samples of practicing primary care doctors across the 10 countries; and
- The Commonwealth Fund 2023 International Health Policy Survey, which collected data from nationally representative samples of non-institutionalised adults aged 18 and older.
Data were gathered from Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. Details about the data collection methodology are in the last section of the report.
Continuity of care
The report presented data on two measures: the proportion of adults with a regular doctor (GP) or place of care; and the proportion of adults with a longstanding relationship with a GP.
Australia was one of seven countries where more than 90 percent of adults reported a regular GP: significantly more than the 87 percent in the US.
However, Australia and the US were the only two countries where less than half of the population “reported having been with their [GP] for at least five years, a significantly lower proportion than in the other countries we analysed”.
The report does not speculate on why this is so, but I suspect that in Australia at least there are two factors at play: a geographically mobile population; and outside major centres, a constant churn in the GP population.
Access to services
The report presented data on three access measures: telehealth; home visits; and after-hours services.
In relation to telehealth, the report presented data on the (what I found a little odd) metric of the proportion of GPs saying they used telehealth in more than 75 percent of their patient encounters.
Australia was one of eight countries where three percent or fewer of GPs reported such high use of telehealth services. The outliers were NZ (13 percent) and the UK (28 percent).
In relation to the UK, the report observes that: “Because telehealth had been introduced within the UK’s National Health Service (NHS) prior to the COVID-19 pandemic, the NHS had much of the infrastructure in place. Patients and physicians were also already familiar with virtual care settings.”
In nine of the 10 countries, two-thirds or more of GPs reported making home visits “occasionally” or “frequently”. The rate in Australia was 78 percent, much lower than Germany and the Netherlands, where all GPs carried out home visits. The outlier was the US, where only 29 percent of GPs provided home visits.
The doctors’ survey asked whether their practices offered appointments at the weekend or after 6 pm during the week. In Australia, 82 percent said they did, the second highest of the 10 countries. By contrast, in Sweden and the Netherlands, only 16 percent did so.
Social needs
The doctors’ survey asked whether they (or someone else in the practice) screened patients 75 percent of the time or more for problems with one or more of: housing; financial security; food insecurity; transportation needs; domestic violence; or social isolation or loneliness.
In the US and Germany almost a third of GPs said they did do, and in France a quarter did. In the other countries the rate was 20 percent of less, and in Australia it was only 13 percent.
The report noted that: “In the US, there is concerted effort by policymakers and payers to make screening more common and standardised. This is particularly important given that compared to other surveyed countries, the US has higher rates of material hardship, such as food insecurity and financial instability, along with a weaker social safety net.”
While Australia does not yet have the same level of social distress and division as many parts of the US, poverty and domestic violence are not so uncommon that GPs would be wasting their time screening for them.
In all 10 countries included in the report, at least half of GPs reported “challenges” in coordinating with social services to address their patients’ needs. These challenges included a lack of information about the availability of social services; lack of a referral system or mechanism; inadequate staffing to make referrals and coordinate care; too much paperwork; and a lack of follow-up from social services.
The rate in Australia was the second highest at 82 percent, just below France with 85 percent. Given the legendary inefficiency of Gallic bureaucracy, coming a close second to France is a remarkable achievement.
Services Australia is clearly failing its clients in many ways, and it is interesting that even GPs find it hard to deal with.
Behavioural needs
Across all 10 countries, 90 percent or more of GPs reported that they were well-prepared to care for patients with mental illnesses or substance abuse problems.
The rate in Australia at 99 percent was the highest across the group.
Care coordination
Across seven countries, including Australia, about two-thirds of people reported that their GP often or always helped to coordinate their care by securing appointments for referred services, ensuring information was transferred, and following-up to make sure care had been provided. The exceptions were Sweden (27 percent), and the UK and Germany (around half).
However, the proportion of GPs who reported that they usually (75-100 percent of the time) received information from specialists about changes to their patient’s medication or care plan was a lot lower in many countries, including Australia, where it was only 53 percent. This is not good enough.
Conclusions and options
The report concluded that “primary care systems around the world are facing challenges”.
Focussing specifically on the US, it pointed to the fact that primary care physicians are paid less than specialists, and that “fewer practitioners are entering the field at a time when the healthcare needs of patients are growing, inequities are widening, and we are asking more of the primary care physicians we do have”. This resonates for an Australian audience.
The report identified a number of options for US policymakers to consider, including:
- Increasing financial support for primary care to support providers “to expand access through telehealth, home visits, and after-hours appointments, and make care more comprehensive by addressing behavioural health and social needs”
- Growing the primary care workforce by “more competitive compensation and loan repayment programs, particularly those that encourage physicians to practice in rural and underserved areas”
- Reforming payment arrangements, moving away from fee-for-service to population-based payments to “enable and incentivise physicians to offer a more comprehensive set of services — such as care coordination or addressing social needs — and give them greater flexibility to deliver the right care at the right time”
- Creating financial incentives to improve coordination between primary care and other physicians
- Reducing the administrative burden on primary care physicians.
While the Australian primary care system performed well on many of the metrics used by the Commonwealth Fund, these options are all relevant to Australia to some extent. In many instances, some programs already exist, such as support for after-hours services, encouragement for doctors to work in regional areas, or payments for case conferencing. However, many medical and health consumer groups would argue there is much more to be done.
An area where there has been little progress over the past 40 years is reformed payment arrangements for general practice. This has been an issue for governments from as early as 1991, seven years after the introduction of Medicare. The MyMedicare scheme announced just before the 2023 Budget is the latest attempt to move towards a more blended payment arrangement.
Let’s hope it will be more successful than past iterations.
• Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20. He is a member of Croakey Health Media. Follow on X/Twitter at @CharlesAndrewMK.
Further reading
• The health system is under stress, and here are some of the ways that is affecting patient care
