Towards a National Primary Health Care Strategy. A Discussion Paper from the Australian Government

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1 Towards a National Primary Health Care Strategy A Discussion Paper from the Australian Government

2 Towards a National Primary Health Care Strategy A Discussion Paper from the Australian Government

3 Towards a National Primary Health Care Strategy: A Discussion Paper from the Australian Government ISBN: Online ISBN: Publications Approval Number: P Copyright Statements: Paper-based publications (c) Commonwealth of Australia 2008 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at Internet sites (c) Commonwealth of Australia 2008 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney-General s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at Acknowledgment Some of the images used for this publication have been selected from a collection of photographs that were taken for use in the Healthy for Life Program. The Australian Government Department of Health and Ageing acknowledges and appreciates the many people who gave permission for their images to be used in Departmental publications. 4

4 Towards a National Primary Health Care Strategy A Discussion Paper from the Australian Government Foreword Our health, the health of our families, and being able to access the health care services we need, are issues of prime importance to us all. This is why the Rudd Government is committed to improving our health care system, and has initiated an extensive program of health care reform. We know that preventative care, primary health care and acute care are all intertwined and interdependent elements of our health system and our reform agenda acknowledges that interconnection. Improvements in primary health care are critical to improvements in the overall health system. In particular, primary health care is vital in turning our health care system more towards keeping people well and participating in life and work, rather than just looking after people when they are sick. Our commitment to developing Australia s first National Primary Health Care Strategy is a key element of this reform process. Primary health care is the part of the health system most Australians use most often and it is supported by many dedicated and hard working health professionals. It is part of our lives, from birth to death, and when we need it, it is usually our link to the other parts of the health system. We need to have a primary health care system that enables people to see the right health professional for their needs, in an appropriate place at the right time. In an era with an increasing burden of chronic disease, that health professional may be their local GP, it may be the general practice nurse, a nurse practitioner or it may be an allied health professional, such as a psychologist, physiotherapist or dietician. This Discussion Paper canvasses important issues. Many of them warrant discussion and a number are likely to result in debate. I would encourage you to participate in this process, so that we can get the best possible result for all of us in Australia who depend on world class health services. The Hon Nicola Roxon MP Minister for Health and Ageing 5

5 From Dr Tony Hobbs, Chair of the External Reference Group As a General Practitioner in rural Australia, I have recently been involved in the establishment of the Cootamundra Primary Health Centre - a new multidisciplinary clinic. I am excited by the opportunities that this new centre provides to deliver quality primary health care to the people in the Cootamundra area. At the same time, I am somewhat frustrated by some of the constraints in the current program and funding arrangements, which impede our capacity to deliver the integrated services most needed in our local community. On a broader scale, I am concerned at the inequities in health care and health outcomes experienced by the more vulnerable groups across Australia, particularly Indigenous Australians and those living in our rural and remote areas. I know for many health care professionals and consumers, the development of Australia s first National Primary Health Care Strategy has been long awaited. It is an opportunity to look carefully at those aspects of our current system which are not working well, and to move towards a system which allows the best use of our professional skills in delivering the health care services needed in our communities. I look forward to working with the External Reference Group, the Minister, and the Department of Health and Ageing in this important endeavour, and I join with Minister Roxon in encouraging your participation. Dr Tony Hobbs Chair, External Reference Group 6

6 Contents Preface... 6 How to provide input or comment... 7 Content of submissions... 7 Confidentiality of submissions... 7 Address for submissions... 7 Questions relating to submissions... 7 Deadline for submissions... 7 Introduction... 8 Why a National Primary Health Care Strategy?... 9 What are the key elements of an enhanced primary health care system? Accessible, clinically and culturally appropriate, timely and affordable Patient-centred and supportive of health literacy, self-management and individual preference More focussed on preventive care, including support of healthy lifestyles Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing and complex conditions Safe, high-quality care which is continually improving through relevant research and innovation Better management of health information, underpinned by efficient and effective use of ehealth Flexibility to best respond to local community needs and circumstances through sustainable and efficient operational models Working environments and conditions which attract, support and retain workforce High-quality education and training arrangements for both new and existing workforce Fiscally sustainable, efficient and cost-effective References

7 Preface Process for development of Australia s National Primary Health Care Strategy The Australian Government has committed to the development of Australia s first National Primary Health Care Strategy ( the Strategy ). Developing the Strategy will require consideration of a wide range of issues associated with the current planning, delivery, governance and financing of primary health care services in Australia, some of which cut across Commonwealth, state and territory responsibilities. Future directions and reforms, to be identified through the Strategy, will need to recognise and build on the many aspects of our system which are working well. Importantly, the Strategy needs to recognise the critical contribution of the many dedicated health care professionals who are delivering services in our communities. An External Reference Group (ERG) of health experts has been convened to support the Government in developing the Strategy. The ERG has membership based on expertise in, and commitment to, primary health care in Australia, and includes General Practitioners (GPs), a nurse, allied health professionals, academics, a pharmacist, and a consumer representative. The ERG is expected to meet frequently during The ERG Membership and Terms of Reference are available on the Strategy website at: primaryhealthstrategy Communication with a broad range of stakeholders about the Strategy and consultation on proposed elements will be critical to its long term success. Input and comment on this Discussion Paper is sought from the broad public, state and territory governments, professional and consumer groups, and other interested people and organisations. In formulating the draft Strategy, the Department of Health and Ageing (DoHA), working with the ERG, will draw on the information it receives from submissions, research and expertise assembled from other sources, including through engagement with other health reform processes. A draft Strategy is expected to be available for consideration by the Minister for Health and Ageing by mid This Discussion Paper is intended to provide a broad framework and basic information on key issues impacting on primary health care. Its purpose is to stimulate input and comment to assist in the development of the Strategy. This Paper proposes 10 elements which could underpin a future primary health care system and for each one provides a snapshot of: What happens now? What does this mean for the community and health consumers? What does this mean for health professionals? Where could changes be made? Input on any aspects of these 10 elements, or on additional matters relevant to the Strategy, is welcome. 8

8 How to provide input or comment You are invited to provide written input or comment on this Discussion Paper. Submissions can be sent by post or . Content of submissions Your submission should include: name and full contact details (including address), company name (where applicable) and designation of submitter. A form for providing this information can be found on the Strategy website at: gov.au/primaryhealthstrategy comment on areas/questions in the Discussion Paper that are of interest to you; any other relevant information (for example, any technical, economic or business information, or research-based evidence) supporting your comments and views; and identification and discussion of any perceived omissions in the Discussion Paper or alternative approaches. Confidentiality of submissions Unless otherwise indicated in the submission, all submissions will be published on the Department of Health and Ageing website. If you wish any information contained in your submission to be treated as confidential, please explicitly and clearly identify that information, and outline the reasons why you consider it to be confidential. Note that general disclaimers in covering s will not be interpreted as a specific request or taken as sufficient reason for submissions to be treated confidentially. Any submissions which include personal information identifying specific individuals will be de-identified before submissions are published. In addition, where submissions focus on issues specifically relevant to state and territory governments, this information may be forwarded to the relevant jurisdiction(s). Address for submissions Electronic submissions should be ed to: Hard copy submissions should be sent to the following address: National Primary Health Care Strategy Secretariat MDP 94, GPO Box 9848 CANBERRA ACT 2601 Questions relating to submissions Any questions relating to submissions should be directed to the NPHCS Secretariat, by at: Deadline for submissions The deadline for receipt of submissions is Friday, 27 February

9 Introduction Health care is a priority issue for all Australians. Generally, our health system is high performing and compares well with overseas health systems. However, for some population groups there are barriers to accessing health care, and health outcomes are uneven, raising questions of equity and fairness. The gap in life expectancy between Indigenous and non-indigenous Australians is the most telling example, but not the only case. Primary health care is the frontline of Australia s health care system. While many Australians may not recognise the term primary health care, it is a term used to refer to the parts of the health system that most people interact with most of the time. For example, around 18 million 1 Australians see a GP at least once a year. In addition to GPs, primary health care services involve a range of health care providers including nurses (such as general practice nurses, community nurses and nurse practitioners), midwives, allied health professionals, pharmacists and dentists. In Australia, primary health care is delivered through a combination of publicly and privately provided services (funded through Commonwealth, state and territory, and private arrangements, including through private health insurance funding). This Discussion Paper is not based on a precise definition or boundary for what should, or should not be, considered as primary health care. While there are a number of definitions available, including from the World Health Organisation 2 and the Australian Primary Health Care Research Institute 3, in practice there is no absolute or consistent view about whether particular settings and services are part of primary health care or not. At this stage, and to allow for Submissions to address possible future directions without being unduly constrained by current service and funding arrangements, the scope of primary health care is left broad. Alongside the development of the National Primary Health Care Strategy ( the Strategy ), other key reform processes include the: Council of Australian Governments (COAG) Health and Ageing Working Group 4 ; National Health and Hospitals Reform Commission (NHHRC) 5 ; Preventative Health Taskforce (PHT) 6 ; and Review of Maternity Services 7. As part of each of these processes, important issues relating to primary health care in Australia are being considered, which can be expected to inform the development of the Strategy. Another important and related process is the development of the National ehealth Strategy, which will have the potential to enable system change to support delivery of broader reforms across the Australian health care system and improve health care delivery. A review of the Medicare Benefits Schedule (MBS) primary care items is also being undertaken by DoHA alongside development of the Strategy with a focus on reducing red tape for doctors, simplifying the MBS, and giving more support to preventive health care. In addition, a number of reviews and long-term planning processes are being undertaken in specific areas relevant to primary health care (eg. review of rural health programs, development of a Fourth National Mental Health Plan and the work of the National Advisory Council on Mental Health) which will link with development of the Strategy. Consumers and stakeholders have shown a very strong interest in health care reform. For example, the 2020 Summit received over 1,100 health care related submissions, and the NHHRC submission process has received over 500. Many issues and suggestions proposed through these submissions are relevant to primary health care. 10

10 Why a National Primary Health Care Strategy? While overall Australia s health care system performs well, we face real challenges with a growing burden of chronic disease, an ageing population, and health workforce pressures. At the same time, the complexity and volume of care delivered and required in the community continues to increase through: changes in hospital services through reductions in length of stay, increased day surgery and, in some rural areas, reduction or closure of hospital services; an increased focus on ageing at home; an increase in care being provided to people in their homes (eg. dialysis, chemotherapy etc) that was previously provided in hospital; ongoing impacts of de-institutionalisation in a number of areas, notably mental health and disability; new technologies which can support alternative models of community based care and have the potential to allow the delivery of some services closer to a patient s home; and better knowledge and expectations of best practice care at both the health provider and patient level. Responses to these issues, to date, have been incremental. The result is a primary health care system in Australia characterised by an increasing proliferation of narrowly targeted programs and funding arrangements, and growing complexity and inflexibility for health care organisations, professionals and consumers. Within primary health care, the Commonwealth has funded subsidised care provided by GPs through the MBS. Over recent years, the MBS primary care items have grown in number and complexity and now include limited access to rebates for some services provided by other health professionals. At the same time, and partly in response to limitations in MBS arrangements, a range of alternative initiatives for blended and targeted payments have been introduced, including the Practice Incentives Program (PIP). The PIP has provided incentives for a range of quality focussed activities in general practice. State and territory governments are also increasingly focussed on primary health care, with a number of jurisdictions having primary health care strategies in place. Alongside state and territory governments traditional community health activities, jurisdictions are funding a range of primary and ambulatory care programs, (primarily targeted at hospital avoidance, such as Victoria s Hospital Admission Risk Program). All jurisdictions are increasingly engaging with private general practice. 11

11 An important focus of these jurisdictional programs is to improve integration between Commonwealth, state and territory funded primary health care services, aimed at reducing fragmentation and improving the patient journey. These have included programs such as the Primary Care Partnerships in Victoria and the Connecting Healthcare in Communities initiative in Queensland which have focussed on improving relationships between service providers in regional areas. As well, state programs focussed on integrated primary care service delivery models include the NSW s HealthOne NSW initiative and South Australia s GP Plus initiative. The introduction of more flexible private health insurance arrangements has also increased the scope for private health insurers to engage with primary health care in the development of programs which reduce the need for hospital admission. This has the potential to supplement the range of allied health services traditionally funded or supported through private health insurance. In this Discussion Paper, current challenges and future directions have been grouped around four key themes: quality of care and health outcomes for consumers; health care service delivery arrangements; health workforce capacity issues; and fiscal sustainability. The Paper focuses more on the potential areas for improvement than on describing current successes. While, as noted above, Australia s health system performs well, this paper is designed to encourage consideration of future changes required to address existing shortfalls. The development of a national Strategy provides an opportunity to address these issues through a comprehensive and consultative approach, to help ensure that Australians have the best possible primary health care system to face future challenges. 12

12 What are the key elements of an enhanced primary health care system? This Discussion Paper proposes 10 key elements which could underpin a future Australian primary health care system: All Australians should have access to primary health care services which keep people well and manage ill-health by being: Accessible, clinically and culturally appropriate, timely and affordable; Patient-centred and supportive of health literacy, self-management and individual preference; More focussed on preventive care, including support of healthy lifestyles; Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing, and complex conditions. Service delivery arrangements should support: 5. Safe, high quality care which is continually improving through relevant research and innovation; Better management of health information, underpinned by efficient and effective use of ehealth; Flexibility to best respond to local community needs and circumstances through sustainable and efficient operational models. Supporting the primary health care workforce are: Working environments and conditions which attract, support and retain workforce; High quality education and training arrangements for both new and existing workforce. Primary health care is: 10. Fiscally sustainable, efficient and cost effective. Key to the proposed Strategy and implicit in all 10 elements, is a focus on ensuring greater equity not only in access to services, but also in health outcomes for all Australians, and on delivering a primary health care system where accountabilities for performance and outcomes are more transparent. Question Are there aspects of a future Australian primary health care system that are not included in these key elements? 13

13 1. Accessible, clinically and culturally appropriate, timely and affordable Objective: All Australians have access to required primary health care services, which are clinically and culturally appropriate to their needs and circumstances, and are delivered in a timely and affordable manner. What happens now? At the core of an effective health system is good access to services being able to see the right health professional, at the right time, in the right place: and in a manner that is affordable and culturally appropriate. Supported by the MBS, most Australians have relatively good access to affordable GP services with an average of 5.1 GP services per capita, and 79.1% of GP services bulk billed. 8 However, access is not uniform, with some parts of Australia and some population groups experiencing gaps in available GP services and closed books, long waits and/ or travel for appointments, or higher out-ofpocket costs to see a GP. There are also barriers to access to quality of care especially longer consultations, preventive care, and referral to allied health providers. 9 These barriers can relate to cost, time and distance, or the lack of services which are culturally appropriate and accessible to the needs of particular groups. MBS benefits paid to patients by location (metro-rural-remote)(per person, ) $600 MBS benefits paid per person $500 $400 $300 $200 $210 $591 $180 $515 Total MBS benefits include GP, allied health, nursing, and other medical services including specialist, pathology, diagnostic imaging and operations. $336 $100 $130 $0 Metro Rural Remote GP, allied health, nursing Total MBS 14

14 Further, funding through the MBS has historically focussed solely on medical arrangements. In recent times this has been extended to a small subset of other nursing, midwifery, dental and allied health services. Services provided by allied health professionals (such as psychologists, physiotherapists, and dieticians) and dentists are funded through a variety of approaches (privately, including through private health insurance, through state and territory government programs, limited MBS access 10, and other Australian Government programs). This means that access to allied health and dental services can vary depending on factors such as: an individual s condition with government subsidised services available for some health conditions but not others; geographical location with variations even within jurisdictions in the availability and timeliness of publicly funded allied health and dental services; and insurance cover, or ability to pay privately, which will not always relate to an individual s capacity to pay. While the importance of multidisciplinary teams in providing primary health care services is increasingly recognised, team-based models of care can be restricted by current program and funding arrangements. For example, while in many practices general practice nurses (subsidised through the PIP in certain areas) are playing a progressively more important role, the funding arrangements to support advanced nursing services including by nurse practitioners are limited. Pharmacists also are increasingly providing professional services and advice as well as traditional dispensing services. Dental health has traditionally had less support than other medical services. The Australian Government recognises the importance of providing equitable access to dental services for those most in need. At the same time, current funding arrangements also mean that some health professionals may be providing some aspects of care which could be delivered equally effectively by another health professional. 15

15 What does this mean for the community and health consumers? While Australians overall are satisfied with their primary health care services, 11 this is not universal. For some population groups, including Indigenous communities, the homeless and people with a disability or mental illness, access to the range of primary health care services they need is limited. Similarly, those living in some rural, remote and lower socio economic urban areas are receiving fewer services, and not necessarily the range of services from different health professionals they need. Also, for those with complex care needs, access to the full range of services they need can be difficult - due to waiting times for public services or out of pocket costs for private services. Lack of access to primary health care services can result in poorer health outcomes, unnecessary and potentially avoidable complications, and hospital admissions. It also means that some people present at emergency departments for primary health care services. Cath is a single parent who lives in a small, rural area with her two children. Cath has depression and cardiovascular disease, and her youngest child has asthma. Both require regular medication and visits to the medical practice in the nearby town. The waiting time for a normal appointment at their practice is usually five days. A standard consultation at the practice includes an out of pocket payment of around $20, but Cath and her child are usually bulk-billed, with the practice receiving an incentive payment for bulk-billing services to concession card holders and children. Cath has been referred for psychological therapy to help address her depression, with the nearest psychologist located in the regional centre, 125 kilometres away. The psychologist charges a co-payment on top of the Medicare rebate. For Cath the biggest problems are having to travel to see her GP and psychologist, the lead times to get appointments, and the need to meet her family s other health care needs and the costs associated with this. 16

16 What does this mean for health professionals? In some instances, availability of services and funding arrangements, rather than clinical need alone, may impact on the primary health care that professionals can provide. For example, less time may be spent on prevention or lifestyle focussed activities, as funding arrangements do not sufficiently support these activities, nor delegation to another health professional or referral to another service. Providers may also face inefficient referral pathways, or complex program eligibility criteria in trying to access the services their patients need. Where could changes be made? Resources for health spending are not unlimited and our health workforce is under pressure. Primary health care service delivery and funding arrangements need to ensure: affordable access to necessary services for all communities, with current inequalities reduced or eliminated; access to services based on clinical need; and health professionals making best use of their skills, in a team environment. Questions How can we ensure appropriate services for all geographical areas and population groups? How could primary health care services/workforce be expanded to improve access to necessary services? What more needs to be done for disadvantaged groups to support more equitable access? With limited public health dollars, how could priorities for accessing primary health care services be determined and targeting of public resources improved? 17

17 2. Patient-centred and supportive of health literacy, self-management and individual preference Objective: Primary health care services respond to the individual preferences and circumstances of patients, their families, and carers, and actively support them in achieving best possible health outcomes. What happens now? This element is about a primary health care system which is designed around supporting the patient, their family and carer(s), to be in control and actively supported in decision-making regarding their care. It is also about a system which is easy for them to use, and helps them to manage their health care needs and stay as healthy as possible. Often referred to as patient or person-centred care, this involves health professionals considering the patient as an individual within a social network where his/ her experiences, preferences, values and needs are taken into account in the planning and delivery of their health care in a way which considers the patient journey in their health care encounter. Along with recognition of an individual s role in decision making about their health care, patientcentred care supports their role in self-care and monitoring. 12 In Australia, there is evidence that suggests health literacy (i.e. a person s ability to find, process and understand basic health information needed to make appropriate health decisions) for some people is below what is required to effectively engage with the health system and manage their own self care. 13 Also, not all health professionals have the necessary range of skills and opportunities needed to support patients self management. These issues are worse for particular groups, where a lack of culturally appropriate services can work against patients engagement with health services. Examples include Indigenous Australians, some other culturally and linguistically diverse (CALD) populations, and those who have disabilities, drug or alcohol dependency, or mental health conditions. Lack of Indigenous identification by mainstream health services can impact on their accessing of appropriate services. There is scope for many health care organisations in Australia to improve and/ or introduce mechanisms for effective consumer engagement and input. While the Royal Australian College of General Practitioner s (RACGP) accreditation standards for general practice include a patient feedback questionnaire, measuring consumer experiences in primary health care has had limited application in Australia to date. 18

18 What does this mean for the community and health consumers? Lack of a patient-centred focus from health care services can mean care is fragmented, patients are poorly informed about their care needs and options and there can be gaps and/ or duplication of services received. These factors can be compounded by poor self management skills, low levels of health literacy, a lack of readily available, reliable and consumer friendly information, and limited health practitioner support. Overall, this can lead to poor adherence to treatment regimes, limited success with reduction in lifestyle related risk factors and worsening clinical outcomes. Without effective engagement with local communities, services and information provided are less likely to be relevant or culturally appropriate. Greg is in his mid 40s and has asthma and related breathing difficulties. Greg tends to see GPs at one of two local practices or a medical clinic when feeling unwell, and has presented to Accident and Emergency at his local hospital when he has had asthma attacks (twice in the last six months). One GP provided a generic asthma management plan for Greg at a previous visit but Greg has not complied with it and does not use asthma preventer and reliever medications as directed, or regularly enough. Greg has been a heavy smoker most of his adult life and though he has cut down, he continues to smoke. Although advised to quit smoking, exercise more and lose weight, Greg has yet to take up this advice and may need better support and information to help him change his lifestyle. Greg does not have a clear understanding of his condition and what sorts of things are likely to provoke an asthma attack. The treatment and advice he has received to date has tended to focus on the problem of his asthma, not on Greg s overall health needs as a person, including what he needs to manage his asthma, and how to address the barriers that are preventing him from making lifestyle changes. 19

19 What does this mean for health professionals? While health professionals are taught principles of patient-centred care during their training, in some work environments there may be limited support, skills, tools and funding mechanisms available to put patients and their family at the centre of care. Instead, the system supports a focus on specific disease processes and managing episodes of care, rather than the ongoing care process or treatment path for the individual patient. Where could changes be made? A greater focus on patient-centred care is increasingly being identified as a key objective for health system reform. The Australian Safety and Quality Commission, in their background paper for the development of a Consumer Engagement Strategy 14 has identified that a person-centred health care system would: emphasise attention to patients and consumers psychosocial as well as physical needs that is, focus on the holistic needs of the patient; focus on a partnership in care between patients, their carers and their health professionals; facilitate active patient involvement in decision-making about treatment and lifestyle options, including taking personal preference and needs into account; and promote effective self-care to support adherence to agreed treatment options and in achieving related necessary behaviour changes. It is also important that consumer selfmanagement education programs are better integrated with primary health care. Questions What is needed to improve the patient and family-centred focus of primary health care in Australia for: individual patient encounters; health professionals; health service organisations; the broader primary health care system? Are there specific strategies that are needed to better support consumer engagement and input? 20

20 3. More focussed on preventive care, including support of healthy lifestyles Objective: All Australians are supported to stay healthy through a stronger focus on wellness, prevention and early detection, and appropriate intervention to maintain people in as optimal health as possible. What happens now? Primary health care has tended to respond to problems already affecting the patient, with the need for treatment and care usually being initiated by the patient. Historically, there has been less attention to preventing the occurrence of problems and maintaining good health. There is scope for a greater focus on preventive care, that is, interventions to detect and reduce the risk of disease and of complications from an existing disease, including supporting individuals with the behavioural changes required to reduce lifestyle risks such as poor diet, lack of exercise or smoking. The RACGP Green Book notes, for example, that of a typical 100 adult patients seen by a GP, would not have had their lipids tested in the past five years, and that would not have had their blood pressure measured in the past two years. 15 Not only in general practice, but in other primary health care services, the scope and extent of preventive activity is restricted. Research also suggests low rates of detection for many significant conditions with, for example, evidence that 50% of people with diabetes and 75% of people with Chronic Obstructive Pulmonary Disease (COPD) were not aware that they had the condition At the same time, the prevalence of key risk factors associated with chronic disease is increasing. 18 Factors contributing to the gap between optimal and current preventive practice include constraints on clinician time, what is funded in primary health care and the method of financing, the limited availability and utilisation of other health professionals, notably allied health professionals, to provide preventive health services, limited engagement with self-management education, consumer understanding/acceptance of lifestyle modification, and lack of quality data, information and decision support systems 19. People who do not access, or who have limited access to primary health care, are also significantly disadvantaged in relation to preventive health care. 21

21 25% Prevalence of obesity (BMI 30+) by sex and socioeconomic status, % Per cent 15% 10% 5% 0% 5 (lowest) (highest) Source: AIHW Australia s Health 2008, fig 4.20 Socioeconomic group Male Female What does this mean for the community and health consumers? Some groups have increased risk of diseases because of social, cultural, socioeconomic or other factors (eg, their place of residence, economic resources, employment status, skills, low levels of education, language and cultural barriers and lifestyles). 20 These factors can make it hard to make changes or adhere to advice on diet, smoking, drinking and other lifestyle behaviours. For example, some people can find it hard to adopt a healthy diet, because it can be more expensive than one based on foods that are high in fat, salt and sugar. What does this mean for health professionals? Preventive care requires approaches that are evidence-based, systematic and sustainable. The RACGP s Red and Green books, strategies such as the Smoking, Nutrition, Alcohol and Physical Activity Framework, and tools such as disease registers and recall and reminder systems are available to support this aim. However, without a systematic and integrated process to guide this work, primary health care professionals are often left to deal with preventive health on an ad-hoc basis while addressing the more urgent demands to diagnose and treat ill-health. 22

22 Where could changes be made? A more systematic approach to preventive care in our primary health care system could involve: improved measurement, clinician monitoring and reporting of preventive activity, supported by financial and non-financial incentives; financial incentives for primary health care providers to incorporate the provision of appropriate/targeted screening services, health checks, and preventive interventions consistent with evidence-based guidelines as part of ongoing care, and to achieve outcomes in these areas (eg. not just detecting smoking but assisting the patient to quit smoking); linking or affiliating patients with primary health care providers to support populationbased preventive health care, including incentives to providers and consumers; improved referral pathway options for risk factor modification and lifestyle related services; improving access to allied health services for preventive care; and targeted prevention activities, including targeted recall and follow-up systems, for particular at risk populations, including socially disadvantaged persons, people in rural and remote communities, and Indigenous communities. Questions How could primary health care be enhanced to better support prevention activities? How could health professionals be better supported to provide lifestyle modification advice and support consumers in behavioural change? How can consumers be linked with local primary health care services to support a stronger focus on population-based preventive health care with national reporting? What measures have been, or could be, effective in addressing prevention for specific population groups (eg. Indigenous, rural and remote, low socio-economic status, CALD)? With limited public health dollars, how could preventive care priorities be determined and public resources subsequently targeted? 23

23 4. Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing and complex conditions Objective: All Australians, particularly those with multiple, ongoing and complex conditions, experience primary health care services which are coordinated across multiple care providers, with transitions across health sectors actively managed and continuity of care supported. What happens now? Australia s primary health care system is a complex mix of Commonwealth, state and territory, and privately funded and delivered services. While it performs reasonably well for many, for the growing number of people with chronic disease, and especially those with multiple and complex conditions, this is not the case. 21 These people generally have multiple complex health care needs, often provided in different settings and by different health professionals and are often at risk of experiencing an acute event. For these patients, the need to navigate their own way through the system and between multiple services and health care providers can be a daunting experience, with poor coordination leading to worsening outcomes, preventable acute events and emergency department and hospital admissions. With an ageing population, and a growing prevalence and burden of chronic disease, these issues will only become more acute. Poor linkages between general practice and state and territory funded services, including hospitals, community health and other community based services, can adversely impact on patient care, for example, through inadequate planning and coordination on discharge from hospital. This may leave patients without clear advice on how to manage their medication, or leave their GP or aged care provider without sufficient knowledge of the treatments the patient has undergone or the services and medications required to care for the patient. Patients can also be affected by lack of coordination or fragmented care between health care service delivery organisations and providers. This can create problems such as: the ordering of duplicate tests; lack of follow-up; conflicting information from different health care providers; and not receiving the appropriate level of care at the right time. 22 What does this mean for the community and health consumers? Especially for those with complex care needs, navigating their way through a complex and increasingly costly and fragmented system can be a source of frustration and difficulty for patients, their carers and families, and can result in adverse outcomes and unnecessary complications. For those with relatively poor access to services, such as in rural and remote areas, lack of ready access to up-to-date and accurate information can impact on the care provided and on patient outcomes. Not all patients and their families have the capacity to co-ordinate their own care, and patients with complex needs, in particular, often require support to navigate through the health system. 24

24 What does this mean for health professionals? While recognising the patient s role in managing their own health needs, overall responsibility for coordinating clinical aspects of care generally falls to a patient s GP. In many instances, lack of alternatives may also see a patient s GP involved in coordinating other aspects of care including daily living support services. While most people in Australia tend to see the same GP or practice for their primary health care (and in this sense are informally affiliated with a health provider for ongoing care), this is different to patient enrolment as used in other countries. Many patient enrolment schemes include active involvement by the patient s primary health care provider in the ongoing management and care of the patient, often with an expectation and incentives to manage the overall health of their enrolled population group. Often, and especially for patients with multiple, ongoing and complex conditions, poor communication and information transfer means that the range of health professionals involved are not well informed of all aspects of care the patient may be receiving, and are therefore constrained in supporting the patient s overall care. Navigating a complex system on behalf of a patient can be a significant and time consuming activity for health professionals. Fiona is 62 years old. She suffers from Type 2 Diabetes and hypertension. Her diabetes is managed by medication, diet and exercise. She regularly visits her local general practice for routine health care including prescriptions and treatment of minor ailments. Her GP has recently completed an MBS GP Management Plan and Team Care Arrangements in consultation with the local pharmacist and podiatrist. With these arrangements in place she is seeing the podiatrist using MBS subsidised-services. Fiona also attends the diabetes out-patient clinic at the local public hospital where she sees the endocrinologist and diabetes educator. Recently, her GP has referred her to a private cardiologist for further investigation because her blood pressure had become harder to control. The cardiologist prescribed a new medication which she filled at a different pharmacy near his rooms. Fiona is receiving care from six different health professionals and services, relying on multiple funding arrangements, and is taking five different medications (including over the counter preparations). No single person or organisation has complete information on, or responsibility for, her care. 25

25 Where could changes be made? A number of Commonwealth, state and territory initiatives have been introduced to support more integrated care. This is also a core objective for GP Super Clinics. These initiatives have been positive, but there remains scope for significant further improvements. Many of those with complex needs would benefit from active support in managing their condition and coordinating their care needs. There should be clear accountability for the total care of the patient, and effective communication and collaboration between the various providers involved. While co-location of service providers is one approach, alternative approaches to integrating service delivery and improving the patient journey for this high need group are also required. The development of an Individual Electronic Health Record (IEHR) has the potential to assist with the management of chronic and complex conditions across multiple care providers and health sectors to ensure continuity of care. Questions What target groups would most benefit from active clinical care and/or service coordination? Who is best placed to coordinate the clinical and/or service aspects of care? How could information and accountability for patient handover between settings (eg. hospital and general practice) be improved? What changes are needed to improve integration between different primary health care organisations? Would there be advantages in patients having the opportunity to enrol with a key provider? 26

26 5. Safe, high-quality care which is continually improving through relevant research and innovation Objective: All Australians have access to safe, high quality primary health care services that deliver evidence-based care and accountability for outcomes, support continuous quality improvement, and reward research and innovation. What happens now? There is relatively little information on the performance of primary health care services in respect to safety and quality, consumer outcomes or consumer experiences. To date, accreditation has often been used as an indicator for measuring safety and quality of primary health care services. The Quality Improvement Council runs a national scheme that accredits over three hundred primary health and community support agencies. A national approach to GP accreditation has resulted in 80% of patient care being provided by GP practices that are accredited against nationally agreed standards developed by the RACGP. 23 Increasingly, supported by Divisions of General Practice and programs such as the Australian Primary Care Collaboratives and the National Prescribing Service, health professionals are looking at clinical performance indicators and other mechanisms (including pay for performance) to drive quality care, and support greater accountability for whole-of-population health outcomes. In addition, the PIP also supports quality primary health care through a range of specific incentives. Delivering best practice care requires a sound evidence-base, but rigorously designed studies are relatively under-represented in primary health care research. 24 Formal and informal clinical networks for promoting and sharing learning regarding innovative models of primary health care tend to operate outside of national frameworks, meaning that the outputs and outcomes they may be achieving are not well-known or taken up more broadly. There is an increasing proliferation of guidelines and other best practice information, but their authorship, status, relevance, and quality may not be clear to health care providers. For those working in primary health care, disease specific guidelines developed for the hospital or specialist setting are often not relevant or useful for managing patients with multi-morbidities. 25 There is an increasing emphasis in primary health care on the need to utilise continuous quality improvement (CQI) approaches to assessing models of care and to providing the evidence for what will work. CQI has potential to facilitate ongoing improvement in care and bring about substantial and sustained improvement in the quality of care. However time constraints, and a lack of financial incentives, have limited the potential for primary health care professionals to be involved in research and CQI activities. 27

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