LESLEY RUSSELL. Can Primary Health Networks (PHNs) Drive Needed Primary Care Reforms?
A strong primary care system is essential to the equity, efficiency and effectiveness of the healthcare system and for improvements in health outcomes. However, the structure and funding of primary care has not kept pace with changes to disease patterns, the economic pressures on the healthcare system, workforce needs and evidence about the impact of social factors on health. In a paper recently published with my colleague Dr Paresh Dawda, we analyse the current operations and funding of Primary Health Networks and explore whether they are fit-for-purpose to drive and foster primary care reforms.
There is a general consensus from all stakeholders that new models for the delivery and funding of health and healthcare services are needed, but mechanisms for fostering innovation and leadership to inspire it are lacking. To quote a recent Grattan Institute report, “primary care policy in Australia is under-done.”
In the absence of government commitments to push forward reforms via Health Care Homes, the Primary Health Networks (PHNs) remain the singular possibility for meaningful reform. It is encouraging to see examples where local innovative efforts responding to local needs, led by local expertise with a willingness to circumvent the many obstacles, are making a difference.
In preparing this paper, we spent considerable time and effort collecting data from a variety of sources on PHN operations and funding (this is included as appendices to the paper). This was no easy task and served to highlight the current lack of public accountability and transparency around a part of the healthcare system that is important for all stakeholders.
How does the Government view the role of PHNs?
The definition of PHNs on the Department of Health (DoH) website and the objectives provided in the Grant Programme Guidelines and the Designing and Contracting Services Guide indicate that the key work of the PHNs involves strategic planning for the commissioning of needed services and the monitoring and evaluation of these. They are also required to address services gaps and deliver value for money.
The focus is clearly on healthcare, clinical services and general practice serving people who are unwell rather than a more expansive view of primary health care that includes the social determinants of health and preventive activities to deliver health and wellbeing. There is some implicit recognition about the importance of prevention and population health data, but the outcomes to be measured are much more narrowly focussed on the provision of medical services, with those who have chronic and complex illnesses as the key target population.
It is tempting to see PHNs primarily as a tool for the implementation of this Government’s political ideology about contestability and competition in the delivery of healthcare services and as a means to enable the Government and the DoH to shunt off hard decisions about priorities in the face of growing needs and diminishing resources. There is no specific mandate or incentive for innovation.
Are PHNs fit-for-purpose to drive primary care reforms?
As identified in the recent evaluation study, building PHN capability and capacity, as well as undertaking the associated change management, will require significant time and effort. A key risk is that new and competing priorities added in by Government could take the focus away from core business. The evaluation highlights that a key strength of the PHN program has been the very collaborative way in which PHNs support each other and work together for the benefit of the network. But the lack of formal communication and collaborative mechanisms and constraints that the business model imposes on information sharing could undermine this.
|The Yes Case||The No Case|
|PHNs have a government mandate||PHNs are too dominated by GPs|
|PHNs must respond to community need and local population data||PHNs have too many responsibilities and too few resources|
|PHNs have links into all parts of the healthcare system||Primary care services remain reliant on Medicare fee-for-service funding|
|There are already pockets of innovation in some PHNs||Concerns that PHNs have had a negative impact on Aboriginal Community Controlled Organisations|
|Specific problems with mental health services have been identified|
|Little is known about quality, safety and outcomes in primary care|
|E-health support systems are under-developed and under-utilised|
|Engagement by both clinicians and consumers with PHNs is not optimal|
What needs to change?
1. Engagement needs to move beyond the prescribed structures of clinical councils and community advisory groups. The Collaborative Pairs Program currently being rolled out by the Consumers’ Health Forum will help in this regard.
2. Changes to what Medicare pays for and how. A pragmatic beginning point that offers a stepping stone for future efforts is found in the recent recommendations from the MBS Review.
3. Mechanisms to enable PHNs to share information. Currently many PHNs are not doing this, citing intellectual property and commercial-in-confidence issues. A central repository for such reports and evaluations and the ability to consolidate their findings is essential. This could be done by building on the current Primary Health Care Research and Information Service.
4. Increased guidance and resources. The governance and work of PHNs has been constrained by lack of formal guidance from the DoH and by lean budgets and limited resources.
5. Capability building and learning systems. If the healthcare system is to function optimally it needs to embed learning and improvement as normalised practice. This requires a paradigm change and whole-of-system transformation with respect to the sharing and utilisation of data at the population, practice and patient levels.
6. Scale up and translational efforts. There are opportunities to borrow (and then adapt) approaches from elsewhere, such as “Scaling Up: a principled approach for primary care transformation in Alberta”.
7. Investment in leadership. This requires meaningful (clinical) leadership development programs that deliver competencies in a set of composite and contemporary capabilities and leadership behaviours.
8. Data collection, analyses, utilisation and feedback. The Australian Institute of Health and Welfare has established a Primary Health Care Data Unit to develop a National Primary Health Care Data Asset. This Data Asset will support the reporting of key primary health care indicators, resulting in a better understanding of patient outcomes, from diagnosis, treatment and experiences within the healthcare system. The Deeble Institute has recently issued a call for the Government to capitalise on this initiative and back the AIHW in the development of a Primary Health Care National Minimum Data Set to assist PHNs.
9. More primary health services research. The failure to continue to fund the work of the Australian Primary Health Care Research Institute and the cessation of the Primary Health Care Research Evaluation and Development Fund Strategy at the end of 2015 left a yawning gap in primary health care research and translation efforts. It is hoped that funding provided via the Medical Research Future Fund for the Advanced Health and Research Translation Centres and the Centres for Innovation in Regional Health will help fill this space.
There is clearly an ability for appropriately resourced PHNs to be catalysts for reform and innovation in the delivery of primary care and there is evidence that some PHNs are doing this very effectively. The case that we make is that the leadership, learnings and insights provided by these PHNs should be better utilised to drive healthcare reform at the local, regional and national level, and that changes in policy, funding and culture are needed for this to happen.
Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney.