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Discussion paper on the future of primary care leaves much to be discussed

Introduction by Croakey: The Primary Health Reform Steering Group has circulated a discussion paper to stakeholders seeking feedback on its recommendations to inform the Australian Government’s Primary Health Care 10-Year Plan.

In the special Long Read below, Croakey columnist and contributing editor Associate Professor Lesley Russell gives an overview of the paper’s strengths and weaknesses, as well as identifying important omissions.

One such glaring gap is the absence of any discussion around the sector’s role in planning, preparing and responding to climate change and its health impacts.

Yet, there is an extensive literature that could have informed such a discussion, dating back to this 2007 paper by the late Professor Tony McMichael and others arguing that “primary health care has an important role in preparing for and responding to these climate change related threats to human health.”

Meanwhile, the need for the sector to address its own emissions, and the role of GPs in climate health advocacy and leadership were topics discussed at the Sustainable Healthcare and Climate Health Aotearoa Conference at the University of Otago this week.


Lesley Russell writes:

The discussion paper from the Primary Health Reform Steering Group that will form the basis for the Primary Health Care 10-Year Plan has finally made an appearance. It was due in September 2020 but was reportedly delayed by the coronavirus pandemic.

The exact status of the discussion paper is unclear. A copy just happened to land in my email inbox, but to date it does not appear to be publicly available; does this mean that discussion participants will be limited to those on some government email list?

The pandemic has served to highlight the flaws, fragmentation and frayed safety net that is the Australian healthcare system while simultaneously demonstrating that universal access to public healthcare services is essential, the importance of population health and prevention, and the centrality of primary care – thus setting the stage for needed reforms.

My takeout from this paper is that its recommendations contribute little new to the reform discussion. The Steering Group might as well have made a few minor updates to the 2009 National Primary Health Care Strategy Report which covers the same topics and the delivers pretty much the same recommendations.

Absent brave leadership and concerted action from all stakeholders – not seen in 2009 nor in the years since – this report is unlikely to deliver the primary care system Australia needs and Australians deserve.

Background

Health Minister Greg Hunt announced the formation of the Steering Group in October 2019, by when  it had apparently already had its first meeting.

The Group was tasked with providing independent advice on the development of the Primary Health Care 10-Year Plan, part of the of the Government’s Long Term National Health Plan (a topic that the Health Minister rarely mentions these days perhaps because the Plan received scathing criticism from public health experts).

The Minister’s media announcement stated that, as the first step in its work, the Steering Group would advise on the implementation of the $448.5 million provided in the 2019‑20 Budget to support doctors to provide more flexible care to Australians aged 70 years and over. That initiative has apparently been converted into the development of a measure to encourage patients to voluntarily register with general practitioners; it’s not clear if the funding from 2019 still exists to support this.

At the time the Steering Group was announced, I was fairly sceptical about where this work was headed. Some of my concerns were addressed – for example, mental health was considered as an important part of the Steering Group’s work. But a whole range of other necessary primary care services (substance abuse, palliative care, gerontology, paediatrics, rehabilitation, oral health, hearing and sight services) are nowhere discussed.

In my critique I highlighted that it was important to understand the difference between primary healthcare and primary care – terms the Minister and the Department of Health and now the Steering Group discussion paper use interchangeably.

Semantics matter – if you are not using the correct language then you are not recognising the exact nature of the problems you are looking to resolve.

Or did the Morrison Government really think a Primary Health Reform Steering Group and accompanying Consultation Group was adequate to address the national need for a Primary Health Care Plan? (See, for example, the language in this document.)

A chameleon document

The paper includes the gobsmacking statement that it builds on “significant national policy work in primary health care reform over past decades” (perhaps that’s a reference to the pile of previous reports on the topic – or did the Steering Group really think that changing Medicare Locals to Primary Health Networks was significant reform?).

However, I found the upfront summary a refreshingly honest assessment of what it calls the “significant weaknesses” in the current structure and funding of general practice/primary care.

These weaknesses include:

  • It does not respond well to the burden of chronic disease, mental health needs and growing rates of frailty.
  • It needs to focus not just on the unwell but on promoting health and wellbeing, population health and prevention.
  • Primary care is poorly integrated into the rest of the healthcare system (and the health system?).
  • It relies almost entirely on fee-for-service and patients’ out-of-pocket costs.
  • There is duplication and waste and slippage of care that sends too many patients into acute care, especially the most disadvantaged.

In short, the discussion paper finds the current system is “no longer fit for purpose”.

The summary talks about the need for continuity of care across time, settings, conditions and people and the need for empowered, patient-centred care.

It outlines the value of more progressive models of care that would bring decision-making about resource allocation and services as close as possible to the communities that receive these services.

And it cites Aboriginal Community Controlled Health Organisations (ACCHOs) as exemplars of holistic, equitable, community-based models of care.

At this point in my reading, I was enthusiastic about what was to come. Especially so as the summary concluded with the statement that “Commitment to implementation should be a point of difference between the ten-year plan and its forerunners”.

Then I moved on to reading the recommendations and my fervour and visions of reform faded. If too many cooks spoil the broth, then I think what the recommendations highlight is that too many medicos dilute the reforms.

That doesn’t mean I’m opposed to these recommendations and pretty much all of them would improve the system if implemented: it just means there is little that is transformative and little that represents a new approach to delivering primary care (let alone primary healthcare).

The paper is saved from mediocrity by some stark, stinging and insightful comments that are sprinkled throughout the recommendations, as highlighted below.

Rather than go through the specific recommendations, I have chosen to pull out and comment on the most important issues as I see them.

Funding

The most innovative recommendations in the discussion paper are those that relate to funding, although even this statement comes with caveats.

The paper calls for reorientation of the secondary and tertiary healthcare systems to better support primary care and funding flexibility across systems to “create funding models to support best practice primary/integrated healthcare to move the system from volume to value.”

There is a specific recommendation that this should be done by leveraging the National Health Reform Agreement Addendum 2020-2025, with the goal of addressing the need for integration across the healthcare system/s variously funded by federal and state and territory governments.

Regional governance frameworks could be used to deliver pooled funding models of care with shared responsibilities between the Commonwealth and States and Territories. These would involve joint governance and planning, fund sharing or pooling and collaborative commissioning by Primary Health Networks (PHNs), ACCHOs and Local Hospital Networks (LHNs).

A minimum percentage of healthcare spending (it is not clear if this refers to all government spending or just federal spending) should be assigned to primary care and some of these funds should be quarantined to address the needs of Aboriginal and Torres Strait Islander people and disparities through ACCHOs.

There is a call for better resourcing and support for comprehensive preventive care. Again, language matters here, as this is a narrower focus on prevention than one that would include addressing the social and cultural determinants of health.

The paper fleetingly mentions block and blended payment models and bundled payment approaches without any details, and “innovative funding models” for primary care services from allied health, non-dispensing pharmacists [sic – surely reflects the input from the medical profession!], nursing, and mental health services.

Sadly, there is no mention here of how other essential primary care services such as healthcare workers, Aboriginal health workers, case management and coordination services might be supported.

And egregiously there is not a word about how a process to move away from fee-for-service might be implemented.

The paper does indicate support for private health insurance funds to be allowed to fund the delivery of what is described as “evidence-based primary care by allied health professionals and nurses.”

A single primary health destination

The recommendations around voluntary patient registration (VPR) are purportedly a major focus of the discussion paper, but they leave much unsaid and there is little to indicate how this initiative might best be rolled out and encouraged.

The paper states that VPR “will enable the primary health care system to better adapt to a medically led and coordinated multidisciplinary team approach to better support coordinated wrap-around care for people.”

There is recognition that VPR will require an array of patient supports such as care coordinators, system navigators and new skills such as health coaching and social prescribing (I could add also links into social welfare and community support services) but no details to cover these needs.

In neither this section nor the recommendations on new ways of working and using technology is there any reference to ensuring better transitions of care and better communications between healthcare professionals in primary care, acute and sub-acute care, and aged care. Yet all these are surely integral to the purposes of a single primary care destination.

Nor is there any discussion of how VPR will be maintained for patients who are transferred to residential aged care or disability care facilities or to palliative care services.

Improved access to primary care services

The discussion paper also has a focus on improving access to primary care for people who have poor access or who are at risk of poorer health outcomes.

Closing the Gap for Indigenous Australians is seen as one of the critical objectives of the Primary Health Care 10-Year Plan, and the discussion paper states that “all actions in primary care should look towards this objective.”

The recommendations are for a stronger role for ACCHOs and an expansion of these services. However, there is no mention of the fact that currently ACCHOs must juggle multiple funding streams and bear the associated administrative burdens.

There is an acknowledgement of the need for improvements in mainstream services including increased employment of Aboriginal and Torres Strait Islander health professionals and health workers.

Sadly, there is no explicit recommendation about the importance of cultural safety for Aboriginal and Torres Strait Islander people, despite so many wide-ranging efforts elsewhere to address the lack of cultural safety in many mainstream health services.

As noted, it is critical there is alignment of directions from the forthcoming 10-Year Plan and the new National Agreement on Closing the Gap, the National Aboriginal and Torres Strait Islander Health Plan and the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and the associated Implementation Plan.

Improvements in access to primary care are also needed in rural and remote communities and the paper recommends both the implementation of community health centres (modelled on ACCHOs), an increased reliance on rural generalists, and “support for local private practices”.

This section really is very weak: there is no mention of the increased problems of integrating care with fly-in, fly-out specialists and distant hospitals.

There is reference to “consideration of the needs” of rural healthcare workers and their families but given the recognised problems with attracting and retaining health care staff, more is needed.

Several recent reports could have assisted here, including:

An expanded primary care workforce

The discussion paper clearly sees the primary care workforce as medical teams headed by GPs and rural generalists, supported by allied health professionals, nurses and midwives.

There is recognition of the need for supportive services such as translators, health coaches, social prescribing link workers, and a peer support workforce (especially in mental health), but these seem to be treated more like add-ons to the primary care team rather than integral team members.

The focus here is primarily on the regulatory aspects of the support workforce than on their roles and who should be responsible for their remuneration.

Reading between the lines, I would say this was a very contentious aspect of the discussion paper and the doctors on the Steering Group won out. I imagine that the arguments that have played out elsewhere about recommendations from the MBS Review (specifically those around nurse practitioners) were also in play here.

The most important workforce recommendations are:

  • A call for comprehensive workforce planning.
  • Increased training in managing mental health disorders for all members of the primary care team.
  • Reforms in how allied health services are funded (without saying what these might be).
  • New models of care for nursing, midwifery and nurse practitioners, including reviews of scope of practice.
  • A secure training pipeline for GPs with improved supports and supervision – with the goal of making primary care a more attractive specialty option.

There is an interesting requirement that “all policy changes are reviewed through an equity lens (including rural and remote) to mitigate unintended consequences.” I wonder what issues gave rise to this statement?

Comprehensive preventive care

This section is decidedly prosaic with the exception of one standout paragraph that states that we must “recognise the fact that the current health system [I think they mean healthcare system!] relies on the ongoing presence of illness, with broad cultural, funding and system change required to reorient towards prevention and wellness.”

This really represents a hallelujah moment in Australian health/healthcare reform and once again highlights the dichotomies in this discussion paper.

But how to translate this into practice?

Innovation, technology, research and data

The discussion paper points to the need to explore and invest in new ways of working and using technology to deliver more holistic, person-centred care. That is rather grandiose; the reality is more simply that better use of digital infrastructure and technologies and improved clinical systems can deliver safer and more effective care.

The discussion paper calls for the creation of an Australian National Institute for Primary Health Care Research, Translation and Innovation and for reinstating the Primary Health Care Research Education and Development (PHCRED) Strategy that existed from 2000 to 2015, when it was defunded.

The need for more resources for health services and primary care research to drive innovation, and processes of continuous quality improvement has long been an issue.

Recently funds have been provided for research through the Primary Health Care Research Initiative but these are minimal ($45 million over 9 years). More needs to be done to build and financially support capacity and capability in primary care.

Australia collects a lot of health data, but mostly these are measure of activity rather than outcomes and the data that is collected is not well utilised to drive quality and safety improvements and reforms.

Presumably a new Institute would have the capacity to undertake these analyses, communicate the findings and inform policy development? In this sense it would be similar to the Centre for Medicare and Healthcare System Innovation proposed by Labor some years ago.

Leadership and cultural change

None of the issues outlined in the discussion paper will happen without leadership and cultural change, and all of the issues (including getting governments to work together on reforms) are easy in comparison to getting brave leadership and new ways of looking at the operation and funding of health/healthcare systems from all the stakeholders involved.

I was somewhat disconcerted by the statement that system reform must “better align business profitability and sustainability with high quality patient outcomes” and see this approach as potentially counter-productive when looking to reform a system that has equity and efficiency as key goals.

I found this statement much more appropriate as a driver for reforms: “[Reform] will require standing against underlying resistance structurally embedded in the health system through its fragmented, siloed and hierarchical nature, promoted largely through funding that incentivises through put and episodic treatment of sickness.”

Who are the leaders who will stand against underlying resistance?

What’s missing?

The discussion paper has several serious omissions.

The first is the failure to address head-on the (clearly acknowledged) problems with fee-for-service in primary care, and how this adversely impacts continued and coordinated care for people with chronic and complex conditions. The flip side of this coin is patients’ out-of-pocket costs and the barriers they pose. Addressing these issues is an essential aspect of primary care reform.

The second issue is that the discussion paper completely ignores the role of specialist care. Presumably the Steering Group saw this as outside their remit, but it’s impossible to see how primary care can achieve the desired goals without reforms to secondary care that make it both more accessible and affordable for patients and more collaborative with primary care.

The paper has recommendations for empowering individuals, families, carers and communities to better manage their health and healthcare needs and services. But all the responsibility seems to be placed with them rather than shared with the primary care team. There is also a flip side to this issue which is better communications from the primary care team.

In moving forward on primary care reforms it will be important to acknowledge previous mistakes and problems and learn from these.

For example, what can be learned from the Health Care Homes trial, now completed? There is a cryptic statement in the discussion paper about “barriers experienced in Health Care Homes” so presumably at least some members of the Steering Group and its Consultation Group have some inside knowledge.

Finally, it is not clear how the needed reforms will be driven at the coalface; there is an implicit assumption that this will be done by PHNs. But are they up to this task?

This is a question Dr Paresh Dawda and I tackled in a paper written several years ago. Our conclusion was that a few PHNs are well equipped and eager to trial innovative models of care and thus well-placed to play a leadership role in primary care reforms at both the local and national level. Other PHNs will need assistance to develop this capability and to ensure that the people they serve are not disadvantaged compared to those in areas with high-functioning PHNs.

The discussion paper calls for greater recognition of the primary care sector’s role in disaster management at both the local and national levels – as exemplified by the pandemic, bushfires and floods. Despite the fact that organised medicine in Australia has recognised and spoken out about climate change and the impact this will have on primary care (see, for example, this statement), there is no specific reference to this in the paper.

The task of boosting emergency preparedness and ensuring “surge capacity” will also likely fall to PHNs.

A recent paper from Central and Eastern Sydney PHN identifies the impact of the coronavirus pandemic on primary and community care providers, outlines CESPHN’s response and identifies challenges and factors that have enabled success. Such learnings from vanguard PHNs should form the basis for the strategy and policies going forward.

Next steps

The substance of this discussion paper is only 38 well-formatted pages – so the Minister for Health has no excuse to not be across its pretty simplistic recommendations. And given that he commissioned it, he can now own and act on these.

The proposed 10-year plan for primary care cannot come soon enough, for healthcare professionals who work in this space and for their patients.

In developing this 10-year plan there are two criteria that must be central – the first is that the voices and needs of patients and potential patients are privileged and the second is that it must be bipartisan because its lifespan will almost certainly outlast that of the current government.

The discussion paper calls for an independent oversight group to provide advice on implementation, prioritisation, evaluation and refinement of the 10-year plan, which will require an Implementation Plan, a Monitoring and Evaluation Framework and of course, secure, sufficient and sustained funding.

A quote from the discussion paper itself sums up where we are, the needed reforms and the language problems in this paper.

This is that the reform:

will impact the culture and current business models in primary health care [sic – I think this really refers to general practice] and will require strong leadership to be implemented effectively.”

Addendum

The paper references the recommendations of the MBS Review Taskforce that relate to primary care. They can be found here.

Follow on Twitter: @LRussellWolpe


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Comments 1

  1. Giovanni Leonardi says:

    I note the introduction by Croakey to this report mentions role of primary care in relation to climate change. This theme has been recently reviewed by an international paper pointing out the value of primary and community care in this area as well as other threats:

    Lauriola, P., Martín-Olmedo, P., Leonardi, G. S., Bouland, C., Verheij, R., Dückers, M. L., … & Zeka, A. (2021). On the importance of primary and community healthcare in relation to global health and environmental threats: lessons from the COVID-19 crisis. BMJ global health, 6(3), e004111.

    Available at: https://gh.bmj.com/content/bmjgh/6/3/e004111.full.pdf

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