It’s long past time to implement primary care reforms — but whose voices are being heard in the discussion?
It is well recognised that team-based primary care is the core component of an effective healthcare system. Well-implemented team-based care has the potential to improve the comprehensiveness, coordination, efficiency, effectiveness, and value of care, as well as the satisfaction of patients and providers. In Australia the transition from general practice to primary care has been incremental outside of the Aboriginal Community Controlled Health Organisations (ACCHOs) and a few state-funded community health centres.
There are two key reasons: general practitioners (GPs) are the predominant voices heard by politicians and the media and access of other potential members of the primary care team to Medicare is restricted.
The Morrison government has moved slowly, even reluctantly, down the reform path towards primary care. The 2018 recommendations from the General Practice and Primary Care Clinical Committee that was established as part of the Medicare Benefits Schedule Review have been largely ignored. (Those recommendations were discussed in an article I wrote for Pearls and Irritations in January, 2019.)
The discussion paper from the Primary Health Reform Steering Group that will form the basis for the proposed Primary Health Care 10-Year Plan was publicly released in June, some 10 months after it was due. I have previously described this as a chameleon document — it provides a refreshingly honest assessment of the weaknesses of the structure and funding of the current general practice/primary care system and concludes it is “no longer fit for purpose”, but its recommendations contribute little new to the reform discussion.
The submissions in response to this discussion paper highlight where the new 10-year plan is likely to go, and that is nowhere near bold, innovative and needed reforms.
The Australian Medical Association (AMA) response, when read together with its recent Vision for Australia’s Health and its 10-Year Framework for Primary Care Reform (released in July 2020), reveals a vision that is narrow and regressive.
The AMA papers tap into all the current memes: a patient-centred focus on prevention and wellness; patient engagement in their care; a focus on evidence-based care with reductions in waste and low-volume care; recognising the environmental and social determinants of health. But when the priorities and approaches are developed and recommendations laid out, the approach is the same-old-same-old.
There is a focus on more Medicare items, with fee-for-service as the primary source of funding for GPs, and a push for additional funds to undertake preventive health and management of chronic conditions as if these were somehow add-ons to current practice. The call for Medicare funding to encourage the introduction of new technologies into practice is not taken beyond a push for more telehealth items (which, for most doctors, means more phone calls not more face-to-face video calls).
Primary care turns out to be general practice with everyone else on the primary care team working under the auspices of the GP. It’s a dog-in-the-manger approach that relegates all non-medical primary care professionals to subordinates, whose only access to Medicare is via the GP, rather than partners in a multidisciplinary team.
There are plenty of the usual AMA rants that make this point. These include “ill-considered cost-reduction strategies, like task-substitution of non-medical health professionals for GP-led patient care” — apparently even in those situations where there is no GP available. And the complaint that “the role of GPs continues to be undermined” by allowing pharmacist prescribing and vaccination, nurse practitioners to independently access Medicare, physiotherapists to issue medical certificates, and midwife-led maternity care.
The submission from the Royal Australian College of General Practitioners and its vision for general practice and a sustainable healthcare system (released in October 2019) echo the same themes. Not surprisingly, its advocacy is for general practice not primary care, and its focus is “mainstreaming and modernising fee-for-service” and increased funding for GPs.
There is a broader approach to primary care reforms in the submission from the Australian College of Rural and Remote Medicine. This is based on the recognition that primary care services in rural and remote communities are necessarily more expansive than those in metropolitan areas and the available healthcare workforce must work across a broader scope of practice. There is more overt support for blended payment models and, necessarily, for improved coordination between GPs/primary care services and local hospital and health services.
However, there is nothing in any of these papers about the need to improve affordable access to community-based specialist care. There is no attention to the biggest barrier Australians face in accessing needed care and prescription medicines — affordability. Out-of-pocket costs rate a mention only to the extent that patients should know what these are. Yet these are issues that affect patient outcomes, lead to more preventable hospitalisations, and increase the burden on GPs to manage patients with chronic and complex conditions.
The issue of the growing inequalities and inequities in access to healthcare services is acknowledged only in the context of improving the health and wellbeing of Aboriginal and Torres Strait Islander people.
It’s ironic that while the discussion paper highlights the value of the community-controlled model for the provision of primary care services, and the effectiveness and value of this approach is well documented, the major medical organisations see this as applicable only to Indigenous Australians.
It is left to community organisations to do the hard work of community consultation around this discussion paper, to present the concerns and viewpoints of patients and the public, and to argue for meaningful reforms.
The submission from Consumers Health Forum highlights the issues neglected by the clinicians — that primary care must address the social determinants of health, dental and oral health, the effects of climate change, and out-of-pocket costs. There is a warning that proposed “reforms” must not create just another system developed by interest groups and experts who tout “patient-centred care” but fail to recognise that patients and consumers must be equal partners in its development.
The submission from Melbourne-based cohealth makes the point that the existing community health model already addresses many of the challenges identified in the discussion paper. It makes no sense to ignore the expertise and experience that resides with such services and with the ACCHOs, especially if this is because of perceptions that this is a model only for vulnerable populations.
The transition to model/s of primary care fit for the 21st century will require profound changes in culture and the organisation of care, in the interactions and partnerships among both clinical and non-clinical colleagues, and in education and training. And it demands bold, brave and inclusive leadership at the political and policy levels. Are the stakeholders up for the task?