Our primary care system needs a philosophical and structural revolution (part two)Sep 7, 2022
One of the unique disadvantages we must deal with as we try and integrate our delivery of health care is the division of responsibility for Hospital care and Primary Care between our State and Federal governments. The tension created, largely around money, makes the desired smooth integration of all health care needs ,in a patient focussed way, impossible. No reform is more important than abandoning this mess by creating a single funder model for Australia’s health care.
For more than ten years I have been venting my frustration herein re the intransigency associated with tackling this problem. It can’t be done without an instrument that is a loved and respected creation of both State and Federal politicians. The suggested instrument would be ‘Australian Health Care Reform Commission’ (AHRC) reporting to a National Cabinet.
In recent months the Liberal Premier of NSW and the Labor Premier of Victoria have jointly called for the creation of a single funder model for the provision of all our health services to truly integrate those services. Better and far more cost effective health care would be the reward. Yesterday Premier Perrottet re-emphasised the need for this reform as he announced that NSW and Victoria would each establish 25 community based ‘Acute Care” centres to treat minor emergencies in a move to take pressure of hospital ED’s. The proposal would see the the centres staffed by GPs and ‘Practice Nurses’ and ‘Bulk Billing’ of all patients would be mandatory.
The establishment of these minor emergency services in the community is good idea and the initiative has worked in countries such as the UK and NZ. (Understandably both struggled with the volume of presentations during the hight of the Covid epidemic). In both countries the major benefit associated with these centres however was the faster more efficient care of patients with these significant but not life threatening acute problems. No waiting for hours in a hospital ED before receiving attention. However they done little to reduce pressures on hospital EDs.
Setting up these acute care centres will not be easy. We have an acute shortage of GPs and many have not been involved in setting fractures, closing wounds or managing an attack of asthma for many years. It is not at all clear that they should be run by GPs and it is not practical to locate them within an existing GP practice. The highly variable number of attendances at such clinics requires all staff to be salaried as money coming in from “bulk Billing’ will be so unreliable. Nonetheless we should try and resource such centres.
It’s important to understand what are the major causes of “swamped’ EDs and hours of delay for Ambulances to be able to unload their patients. It is not ‘minor emergencies’. Our public hospitals are literally being overwhelmed by the demands of older Australians with severe chronic diseases. Many are ‘frequent flyers’ having three or more admissions a year.
Many must remain in hospital even after an acute episode of unwellness has settled as they have no place to go. They may need weeks for social workers to find a place for them in a nursing home for example. This problem has steadily worsened and is the reason why so few beds are available for planned surgery admissions. This in turn has driven surgeons to focus on private hospital work and many, who will struggle to meet the costs, turn to Private Health Insurance (PHI). For both direct and indirect support for PHI we spend about 11 billion dollars a year that would be far better spent on funding the reforms we are discussing.
While the ultimate solution to this excessive demand is to reduce the incidence of chronic diseases, many of which are potentially avoidable, we need to urgently improve monitoring for failing health in the community when it is possible to take steps to escape the need for admission to hospital. As I pointed out in part one of this discussion 650,000 or more admissions to hospital each year were avoidable. How do we do that?
Well that brings us back to the reforms described in part one of this discussion. We must create a primary care system resourced to facilitate the prevention of chronic diseases while better managing in the community not hospitals problems associated with chronic, often complex disease.
The system we need to find at the end of the reform journey is clear enough I believe. The system will focus on the needs of the individual with an emphasis on prevention and timely access to quality health care based on need, not one’s personal financial well being. nAn Australian Healthcare Reform Commission will have become the Australian Health commission which holds the single source for funding our health system.
Australia will be divided into a number of Regional Health Districts which will fund integrated Primary, Community and Hospital care. Australians will be offered the chance to enrol in a ‘Medical Home’ where an interdisciplinary team of health professionals will offer integrated personal care.
Health literacy will be facilitated. Continuity of care will help early detection of problems that could become chronic if not managed. Complex diseases will be team managed with a ‘Case Manager’ facilitating delivery of care from needed members of the interdisciplinary team. Some practice nurses will follow more fragile patients offering care in their homes and community helping to abort episodes of illness that could require hospitalisation if not managed promptly. Public hospitals will be able to manage the demand for planned surgery in a timely manner.
Well if that is the destination what about the journey? We need urgent political and community discussion about the desired changes. NSW and Victoria have laid down the challenge to urgently pursue a singe funder model for our health system. The role and structure of PrimaryCare in that system must be exciting enough to again haver many graduating doctors enthusiastic about becoming GPs.
Bulk billing is understandably collapsing. Other countries have instituted a payment system for GPs that is part ‘fee for service’ and part salary. These are fiscally difficult times as we all know but the scarcity of quality primary care which is a real possibility will not only cause much suffering but will be very expensive. The committee reporting before Xmas to Mark Butler should recommend the immediate introduction of blended payments to ensure the viability of GP services to Australians. Eventually I am convinced all the team members of a Medical Home should be salaried employees.
The Federal Government should call for expressions of interest from health professionals re establishing trial Medical Homes along the lines I have described. Funding these trials is necessary to convince government and the public that the model is right for Australia.
For more than 30 years based on long experience of health care delivery in Australia, I and many others, have been agitating for philosophical and structural reform of our complex and inefficient health system The chorus singing for change is now enormous and importantly the song it is singing is harmonised. This is the best opportunity I have encountered for real reform we must not waste it.
Read Part One of this issue published 6 September.