Investment in Primary Care

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1 Investment in Primary Care Doris Young Professor of General Practice University of Melbourne General Practice and Primary Health Care Academic Centre

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3 Definitions What is Primary Care? Primary Health Care? Primary Medical Care?

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5 Cardinal Characteristics of Primary Care First point of patient contact Delivery of long term patient focussed care Comprehensive in range of services provided AND Co-ordination of other health care services received by the patient Starfield, B. and Shi, L. (2007), 'Commentary: Primary Care and Health Outcomes: A Health Services Research Challenge', Health Services Research, 42 (6 Part 1 (December)),

6 Why Invest in Primary Care? Many argue that evidence base for a strong primary care is unequivocal as countries with strong Primary Care have: More equitable access to health care Lower health care costs Better health outcomes Starfield, B., Shi, L., and Macinko, J. (2005), 'Contribution of primary care to health systems and health', Milbank Quarterly, 83 (3), Starfield, B. (2008), 'Refocusing the System', New England Journal of Medicine, 359 (20),

7 Pyramid of Care What a few people need: complex interventions, hospitalisation What some people need: Treatment of complications What a lot of people need: Intensive surveillance, complex medication, Rx exacerbations What everybody needs: Information, self-care support, surveillance, preventive care, basic medicine

8 Variations in Development of Primary Care System Public vs Private financing Orientation towards hospital-based or community based health care Degree of autonomy of physicians Role of incentives Extent of decentralisation in decision making Gate keeping role

9 Local Contexts Important High and Middle Income countries Low Income countries with large populations Taxation systems Funding of health care services Health Insurance funds Geographical spread of populations Disparity of distribution of work force

10 PHC Systems Comparisons 2012 Dimension Australia Canada NZ UK Patient enrolment Primary Care Team NO (2012 diabetes CC trial ) GP Practice Nurses (PN) Allied Health No Yes -With PHOs Yes Family physicians Nurse Practitioner (NP) Allied Health GP, PN, Allied health GP, PN, Community nurse, Health Visitors Regional Organisational Structures Divisions of GP ends June 2012 Medicare Locals 62 by Jul 2012) Primary care Partnerships Family Health Team Family Health Networks District Health Boards Primary Health Organisations Independent Practitioner Associations Primary Care Trusts ceased Now back to GP control and co-ordination by Apr 2013 Performance Quality frameworks National Performance Quality framework No Performance Quality framework Quality Outcomes Framework RACGP voluntary trial of 30 QI in Funding systems Medicare universal health care system (tax) Gap payment FFS,Salary Capitation, Sessional Capitation GP contract (QOF 25% income) Capitation payments FFS and blended payment eg SIP;PIP

11 Ingredients for an Effective Primary Care System Responsible for a Population Gate keeping role Incentives for providing primary care Leadership Professionalism Financial Workforce Measure Performance

12 Types of Payment for Primary Care Doctors Salary- independent of workload or quality Capitation- people on a doctor s list Fee for Service- individual items of care Quality- meeting quality targets (indicators) A mixture of the above

13 Financial Incentives Patient enrolment Payment for process of care Pay for Performance (UK Quality outcomes framework) Private Insurance payments User pays- equity and access over or under servicing Sustainability- rising health care costs

14 Quality Indicators UK: Quality Outcomes Framework (Roland, M. (2004), 'Linking Physicians' Pay to the Quality of Care -- A Major Experiment in the United Kingdom', NEJM, 351 (14), ) Pay for Performance Introduced in 2004 Complex set of clinical organisational and patient experience indicators (25% of GPs income) Evidence exists that it improves health outcomes :%BP< 150/90 increase from 48 to 83% ; TC <5mmol/l from 17% to 80% from 1998 to 2007 (Campbell S etal. NEJM 2009;361:368-78)

15 Australia: RACGP (2012) Voluntary and emphasise self improvement in providing quality and safety care Trial indicators covering 30 most common presentations e.g. role of statins in CAD, broad vs narrow spectrum antibiotics, screening for smoking/alcohol No funding incentives Not attached to practice accreditation!!!

16 So, Future investment of Primary Care Development in Hong Kong : Evolution vs Revolution??

17 Challenges for Hong Kong Primary Care Systems and Professionals Fee for service solo practices 90% private practice-user pays No patient population Diversity of primary care providers Community choices Differential access to care: public vs private; generalist vs specialists; acute vs chronic care Quality and Safety?

18 Investments in Primary Care Strengthening the core principle of Generalism within Primary Care (The general practitioner) Strengthening and supporting the research base of Primary Care Strengthening and supporting teaching and training in Primary Care Clinical engagement is vital

19 Strengthening Generalism in Primary Care There is observational evidence that generalist Primary Care contributes to achieving better and more equitable health outcomes A practitioner must integrate health care within a relational context, continue that care and support The generalist offers a bridge between the biomedical and the social AND delivers care with a health professional team

20 Strengthening Primary Care Research Within Primary Care strategy there is established a framework and support for Regional Primary Care research networks Such networks be linked to academic Departments of General Practice and Primary Care with links to nursing and other primary care clinical professional groups Should include structures for community education, engagement and representation Such networks should be supported by targeted funding and contractual arrangement allowing dedicated time and resources for active participation of practitioners.

21 Integrated approach to building sustainable Primary Care leadership and research capacity Practitioner engagement in research through Primary Care Research Evaluation and Development practitioner fellowship program Centres of Excellence in Primary Care research (chronic illness, quality and safety, innovative health services models )

22 Strengthening Teaching and Training in General Practice and Primary Care A framework and support for community based teaching for health professional students Targeted funding and contractual arrangements that allow dedicated time and resources for engagement of GPs and other Primary Care clinicians as teachers Further development of Inter Professional Education and Practice (IPEP) opportunities to mirror team care in primary care practice

23 Where some of us are at now? USA: patient-centered medical home (PCMH),accountable care organization (ACO) decreasing number of Primary Care physicians UK: QOF continues, GP led consortia given 70% entire hospital budget to commission services from hospitals power back to GPs Australia: RACGP Quality indicators, Personally Controlled Electronic Health Record, Medicare Locals- power to managers,1000 GP Trainee China: 300,000 GPs trained by 2020 ; 5+3 mode &CME; shift care from hospital to communityquality of primary care, payment of doctors

24 What about Hong Kong? No Magic bullet Takes time Avoid constant change Clinically and professionally led-integrated Community buy in and support Continuous Quality Improvement Public-Private partnerships Locally relevant and ownership

25 Key References Scott A., Jan S. Primary Care. In: Smith P., Glied S. (eds) Oxford Handbook of Health Economics. Oxford University Press: Oxford,

26 Thank you for your invitation

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