JOHN DWYER. A shared vision for restructuring primary care in Australia.13/08/2016
At last the clouds are dispersing, the sun is shining through and one can see a splendid vision of a restructured primary health system that meets the needs of contemporary Australia. For the first time that I can remember, there is a consensus among informed consumers and health professionals that enthusiastically supports the introduction of “Patient-Centred Healthcare Homes” as the primary care model we need to deliver cost effective and equitable integrated primary care. The model has been or is being implemented in eleven OECD countries and the results are most encouraging. Just published is a position paper from a “roundtable” exercise involving The Consumers Health Forum, the George Institute, the Royal Australian College of General Practice, the Menzies Centre for Health Policy, Sydney University and the Australian National University. Their support for the model echoes that of the AMA and the Royal Australasian College of Physicians. I am providing this impressive list of supporters, as consensus on healthcare reform in Australia has been held captive by vested interests for so long.
I described the desired model in some detail herein with a contribution entitled “Medicare and the 45th Parliament” but the essential features of the model involve a physical entity (practice), one’s “medical home”, populated by a team of health professionals offering all the services required for contemporary primary care, namely, prevention strategies that involve improving enrolled members health literacy, early detection and treatment of conditions that have the potential for becoming chronic conditions, “in house” treatment of established chronic diseases and care in the community for many who currently are sent to hospital. Doctors, nutritionists, a social worker, various nurse specialists, physiotherapists, occupational therapists and even a dental hygienist might staff a typical Medical Home. The exact nature of a given team is determined by the needs of the local community.
The Government has recently announced plans to establish a trial of “Healthcare Homes” with the aim of “providing continuity of care, coordinated services and a team based approach according to the needs and wishes of the patient”. Few details are provided but the concept is far removed from the fully resourced Medical Home discussed herein, the effectiveness of which is supported by a strong evidence base.
The government’s plan is only open to patients with chronic disease and more than one morbidity, precluding it from being part of a family-orientated care system. It is doctor centric with no provision for allied health services. The initiative does not supply any resources for prevention strategies and while GPs who embrace the plan will need to be accredited, how this is to be done is not clear. It is suggested that the plan will involve 200 practices caring for 65,000 patients and cost 21 million dollars. This will provide $323 per patient over two years and as such is hopelessly underfunded. The government’s plan relies on Primary Health Care Networks (PHN) providing many non-medical services. As constituted a PHN has little chance of providing such care as there are too few of them asked to cover large populations over large areas. There are only 31 PHNs for all of Australia, one PHN for all of WA outside of Perth, and one for Tasmania, population 555,000!
While the consensus paper discussed above is excellent and supports the need to trial fully resourced healthcare homes that cater for all the needs of enrolled patients, there are a few matters that are not adequately addressed. The model described does not discuss the need for a healthcare home to have team members who can help care for fragile patients in a home or community setting. Internationally this has been found to be an essential requirement if unnecessary hospital admissions are to be avoided. We have about 600,000 hospital admissions per year that could be avoided with an effective community intervention. The single largest cost saving associated with medical homes comes from fewer hospital admissions.
The role played by PHNs, currently poorly defined, needs to change and be targeted. We need to have our 31 subdivided to align PHN “satellites” with local hospital districts where they will work in a “Hub and Spoke” fashion with local medical homes. They could even become commissioning agents for such practices. Internationally such hubs provide essential services to affiliated practices. IT expertise, bulk purchasing, research capability, continuing education, support for electronic patient records are some of the benefits they could provide. As the medical home model is based on a move away from fee for service payments for the management of chronic disease, clinicians will need to document health outcomes to justify the capitated fee paid. A hub PHN can provide the expertise required for this imperative.
Most importantly the consensus paper, in discussing implementation, while rightly emphasising the need to use current clinical leadership to drive the initiative does not discuss the need for a formal health reform commission to co-ordinate the diverse elements of the restructuring. Such an agency populated with appropriate clinical, consumer and bureaucratic expertise is essential. The Commission could run the proposed trials while pursuing initiatives that require simultaneous exploration. Determining capitation fees for various clinical and geographic circumstances, defining the health outcomes to be collected, health workforce programs to prepare existing and future clinicians for their team role, educating the public about the benefits of the model, advising government on the financial support required and much more. Establishing this model of primary care should involve trials of fully resourced healthcare homes offered by a coalition of the clinically willing. Internationally such “bottom up” first steps have been most successful in avoiding consumer and clinician backlash. The new model is not being imposed and indeed the old will be there with the new for some time. We can expect full implementation of the patient centred health care home program to take a decade.
Economic evaluation of progress with the model elsewhere allows us to make some confidant predictions. Initially we can expect to find much unmet need as patients enrol and are assessed by their home team. We currently spend about 20 billion dollars a year paying for primary health care through Medicare. We can expect that to almost double over ten years if this program becomes the norm. Yet we can also expect total health expenditure to be no more than a very acceptable 11% of GDP, which will represent a considerably larger dollar amount than it would today. Hospital costs dwarf expenditure through Medicare. Having a healthier population, working more years with many fewer hospital admissions will save billions of dollars. Indeed International comparisons suggest that for every dollar spent on fully resourced primary care saves two dollars that would have been needed for hospital care.
Before election the Prime Minister, in announcing the Healthcare Home initiative, said that his government “had listened to clinicians and the community”. Well he must have been distracted and not heard accurately. Now however we should be able to expect that the consensus on what needs to be done is so persuasive that his government will ditch plan A and embrace the model described hear and so strongly advocated by so many.
John Dwyer is Emeritus Professor of Medicine at UNSW.