Pearls and Irritations

One thing primary care has a lot of is reports about reform. But despite a significant investment in reviews, consultations, and paper over the last five years, not a single cent has been invested in transforming these words on paper into policies which benefit patients and practitioners. Even though the previous government’s ten-year primary care strategy was released on Budget night, no dollars were allocated for implementation.

The problems are well known. Bulk billing of general practice visits is at an all-time high but anecdotally is under threat. Out-of-pocket payments for general practice visits are going up faster than inflation. The number of GPs is not keeping pace with growth in the patient population. The skills of many health professionals are not being fully used. The funding system does not encourage outreach from a general practice, and rewards short rather than long consultations. And general medical practice is rarely multi-disciplinary.

But there is room for hope. The Labor Party announced a ‘Strengthening Medicare task force’ before the last election to examine the problems of primary care. Importantly, the signs are that this will not be just another talk fest. It will be chaired by the Minister for Health, Mark Butler, committing his time and reputation to reform, so if nothing comes out of it he will have a whole omelette on his face.

His job is easier because the new government has put money on the table – about $250 million in a full year. Primary care needs are great, of course, so the task force will be about what should be the priorities for allocating these funds. It is unlikely that primary care can be ‘fixed’ with a quick six month process and $250 million extra per year, so those priorities need to be about real benefits to patients and real primary care transformation if further stages of reform are to be justified to Treasury and the voting public.

Primary care policy needs to be seen as national, rather than Commonwealth, with the states given a greater role in policy development, funding and implementation. States already fund community health services — some states more than others — and these vestiges of a Whitlam-era initiative still show what good primary care looks like: accessible, locally-focused, multi-disciplinary, and preventively-oriented. In 2022, we would add digitally-supported.

Those characteristics point to some directions for reform. How much of the $250m will be to redress the slow indexation of GP rebates in recent years? And what will patients get in return in terms of increases in bulk-billing rates or reduced out-of-pocket payments?

But the big focus should be on building a primary care system, not simply a primary medical care system. We need a review of the digital infrastructure required to support high performing value based primary care. But more fundamentally, a focus on the ‘I’ word, integration, and the ‘M’ word, multi-disciplinary is required. Both are critical in an environment when more people have multiple chronic diseases, with their co-morbidities including mental illness as well.

‘Integration’ has multiple meanings. Importantly, organisational integration — a very commonly advocated strategy — doesn’t necessarily breed service integration. Even if all primary care services were merged organisationally into one large happy family—a political impossibility in Australia, given the very strong role of private provision—there is no strong evidence that bigger is better in primary care.

Strengthening some interrelationships necessarily weakens others. For example, strong coordination of community and inpatient mental health services inevitably implies weaker links between community mental health and generalist community services and between inpatient psychiatry and other inpatient services. But, paraphrasing Abraham Lincoln, ‘You can integrate some services for all of the people or all services for some of the people but you can’t integrate all services for all of the people’.

Coordinating and integrating services mean making difficult choices and trade-offs. The proliferation of primary care service programs by both Commonwealth and state governments is, in part, a testament to the success of governments in avoiding such decisions. It is easier (and more politically popular) to announce a new funding program than to encourage existing health services to collaborate in meeting service gaps. However, just as with politics, all integration is local and must take account of local circumstances, population needs, and local service gaps. This framing of the integration conundrum raises questions as to how governments can support better integration of services as the increased prevalence of chronic illness requires. Perhaps the Strengthening Medicare task force could augment the new money allocated by sweeping some of the existing programmatic confetti into its remit, to foster a more integrated approach to local provision. Or maybe this should be part of the next wave of reform.

Integrated care is essential for good primary care, but integration of whom for what? The atomised nature of Australia’s primary care system and the increasing prevalence of chronic illnesses make the integration challenge more difficult in Australia than in the United Kingdom (UK) or Canada, which both have a single level of government responsible for all health care and, especially in the UK, an organised system in the form of the NHS. Nevertheless, there are good examples of integration occurring in Australia, and international examples of better integration can provide lessons for how to move faster on integrated care in this country.

But siloed funding — where services are funded in narrowly defined programs — and multiple funding and provision arrangements with some services covered by Medicare and some not, and some salaried in state-funded community health services and some fee-for-service, create a very complex reform environment. Reform will inevitably change how revenue flows to providers, leading to uncertainty. Powerful entrenched interests can be expected to guard their current turf and conspire to make reform difficult. The stakeholder magic that converts private interest into (alleged) public interest will make reform even harder.

The epidemiological transition — where there is increased prevalence of chronic disease and multi-morbidity — should be associated with changed treatment patterns:

more integrated care, more multidisciplinary care, more teamwork and inter-professional collaboration. This again suggests an ongoing relationship between provider(s) and patient, identifying what is wrong and working with the patient to meet their needs.

If primary care is to be the foundation of the Australian health care system, as the rhetoric regularly espouses, decision-makers and health professionals need to step back to identify the critical changes that need to occur over what time frame. One of these will surely be voluntary patient enrolment whereby if a patient enrols in a practice, the practice gets an extra annual payment which varies with, say, the age of the patient. The extra payment would allow the practice to employ nurses and other health professionals to provide additional care, including preventive care, to the patient.

This will inevitably involve winners and losers in terms of the turf wars, and so there needs to be compromise to effect the necessary changes, and negotiating this will be a key challenge for Minister Butler as chair of the Strengthening Medicare task force. But there are some positive signs of shifts in stakeholder positions in recent years. The medical profession, for example, which has consistently argued against voluntary patient enrolment over decades, is slowly moderating its position and now is cautiously in support.

A recent review of strategies to improve primary health care in low- and middle-income countries identified four necessary ‘strategic levers’: political commitment and leadership; governance and policy; funding and allocation of resources; and engagement of communities and other stakeholders. All are necessary in Australia too, and all are lacking. Importantly, the first on the list is political commitment and leadership. The Strengthening Medicare task force is a sign that there is now committed political leadership, creating a window of opportunity.

Whether a transformed, contemporary primary care nirvana occurs is more a matter of hope than expectation. Primary care was not identified as a priority in a recent national road map of ‘long-term health reforms’. But it is nevertheless possible to see a scenario where there is much more collaboration on the ground, much more joint funding, and much more cooperative professional working in the interest of better care for patients.

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