John Dwyer. Primary healthcare in Australia reaches the crossroads.

Mar 27, 2014

 When I graduated some 50 years ago more than 50% of my class pursued careers as General Practitioners. In the last available survey of the career intentions of graduating medical students only 13% said they were interested in Primary Care and only 13% of those who would consider a career in rural Australia. Currently more than 45% of the General Practitioners available to rural based Australians are overseas trained doctors most of whom are working there as provider numbers were not available for metropolitan practice. The average age of working General Practitioners is 55 years.

Young doctors considering vocational training cite positive and negative reasons for their disinterest in Primary Care. Many other career opportunities seem more attractive as they provide much higher average incomes and part time employment provides funds sufficient for many. General Practice training is equally as vigorous as that required for other specialities but “GPs” are not paid as specialists and often feel their vital and increasingly unique skills are underappreciated. Tales from GP land tell young graduates of practice subjected to stifling bureaucracy, the need to “bulk bill” and thus to practice “turnstile medicine” with short consultation times being unsatisfactory to both patient and physician. These and many other impediments place us in real danger of having far too few GPs to provide us with quality Primary Care in the near future.

All this reality is addressed by rhetoric from government reassuring GPs that they are the “heart and soul” of the nation’s health care system. The fact that the Federal government is freezing cost of living adjustments to Medicare rebates for four years and considering strategies to reduce our 18 billion dollar annual Medicare expenditure should not be taken personally. As I have commented here previously, we should be spending more not less on Primary Care but Primary Care that is restructured to better meet contemporary needs. This would include reducing the seven million bed days utilised in public hospitals by avoidable admissions. Hospital expenditure dwarfs Medicare spending.

Is it possible that the introduction of a new model of Primary Care could produce better, more cost effective health outcomes for Australians and at the same time attract a new generation of doctors to Primary Care? International experience would say the answer to both questions is a definite yes. We know what that new model should provide; infrastructure to support preventative strategies, early diagnosis of problems that, left untreated, could become chronic, team management of established chronic and complex diseases and care in the community for many who are currently being sent to hospital. The model described is usually referred to as “Integrated Primary Care”  (IPC) which, to use American parlance, provides individuals with a “Medical Home”.

IPC is structured around teams of health professionals working in the one practice. It is not doctor centric and provides individuals who enrolled in the IPC program with access to doctors, nurses and a range of allied health professionals including dental hygienists. Doctors cannot provide all the services described above but here can concentrate on those things only doctors can do. Well run IPC programs in the UK, the US, New Zealand and many other countries have demonstrated their cost effectiveness, better health outcomes and fewer admissions to hospitals for the patients of such medical homes. Perhaps most importantly in our context, they attract and hold GPs who enjoy better job satisfaction in this form of practice. An international trend has IPC practices offering their doctors flexible arrangements for remuneration. Rapidly payments based on a “fee for service” (FFS) are giving way to “blended payment” options. What is this all about?

Many Australian GPs want to move away from the FFS model with very significant numbers joining large corporation owned practices where they are salaried or paid on contract. FFS at bulk billing rates does not work well for patients with chronic diseases and complex needs. A number of countries are offering their GPs fixed annual payments for their care of complex patients while those seeking a “one off” service are still charged a fee. In New Zealand more than 85% of the GPs work in such a system with about 80% of their income fixed with the remaining 20% coming from traditional FFS payments. Such arrangements are in the medical news here in Australia as Minister Dutton has publically expressed cautious interest in seeing how this could work in Oz. In the US 60%of GPs are paid in this way and this is increasingly so in the UK. There is an abundance of data showing that blended payments within the IPC model produces better health outcomes with fewer hospital admissions.

Overseas experience with this radical reform tells us that its implementation must be a “bottom up” one available to willing participants and never forced on the medical profession. Space doesn’t permit detailed discussion of the mechanisms involved in establishing this system but if we were to follow say the NZ model it would look something like this. Our Medical Locals would become Primary Health Care organisations and holders and distributors of a primary care budget provided after careful analysis of local needs. GPs or IPC practices would negotiate for a fixed payment for their care of their patients with chronic diseases and in return would provide quality/outcome data associated with the use of that money. Financial incentives are built into the contract to encourage “best practice” management.

Our medical profession, government and citizenry, should not be concerned by the exploration of these changes. The evidence is strong that, done properly, the results are very positive and the model attractive to clinicians and patients alike.

John Dwyer is the Emeritus Professor of Medicine at the University of NSW.

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