Our primary care system needs a philosophical and structural revolution (part one)Sep 6, 2022
It is totally appropriate to use the word ‘crisis’ when describing the current state of Primary Care in our country. Our ‘General Practitioners’ are increasingly giving voice to their frustration with the structures and strictures within which they are expected to deliver health care to Australians. Their disillusionment is infectious with recent studies reporting that only 9-15% of graduating doctors are contemplating careers as “GPs”.
Our brand new government is well aware of the situation and has pledged $750 million to improve Primary Care and has created an advisory group, populated by good people from the health professions and community, which is to present suggestions for change by Xmas this year.
“Off the bat” the Albanese government wants to see many GP practices creating Acute Care Clinics, free standing or co-located with their current practices, to treat non-life threatening emergencies. This to take pressure of hospital emergency services. They are also very interested in having GP’s patients ‘enrol’ in a practice to promote continuity of care. Both sound like good initiatives but in fact represent well meaning but ill informed planning as I will explain.
Fundamental problems with our primary care system
Primary care in Australia is doctor and ‘sickness’ centric. Federal Governments, responsible for funding the system have made it impossible for Primary Care to fully and seamlessly integrate the nursing and allied health skills that must complement a physicians care to provide best possible clinical outcomes for patients.
No structural flaw is more damaging that the failure to provide our Primary Care system with the infrastructure necessary to help keep people well! Less that 1% of the total health budget is spent on prevention.
Great pressure has been placed on GPs to ‘bulk bill’ Canberra for the care of an individual. That means accepting the dollar amount for a service that is proscribed in the Medical Benefits Schedule (MBS). Until recently about 80-85 percent of GPs did just that. This is a ‘Fee for Service’ system that involves paying for volume not necessarily quality and is an approach abandoned by most developed countries because of the perverse incentives generated.
MBS payments have not kept up with inflation. The costs involved in running a practice have far outstripped any increase in MBS payments to GPs. It was nothing short of insulting for the outgoing health minister’s response to falling bulk billing rates to offer to GPs an additional 60 cents for a consultation. For a 20 minute consultation a GP will get from the MBS just under $40.00. Recent studies suggest that the average GP makes about $100.00 per hour which must provide personal income and practice costs. In discussing the urgent need to vaccinate children under 5 years of age against Covid-19, my GP told me that if he got involved it would bankrupt his practice.
GPs are highly trained specialists whose post graduate education is every bit as demanding as is the case in other specialities. Despite the reality that they are uniquely qualified to take an holistic approach to the social and pathological complexities of their patients, they are all too often not recognised as ‘specialists”. They certainly are not payed anything like the dollars earned by other specialty colleagues. A GP told me recently that all too often the response of a patient in whom he has just confirmed a diagnosis of Diabetes is “Well who are you going to send me to?”
Much of a GP’s clinical life is involved with writing out clinical plans for their patients that others will deliver. The skills of our GPs are under appreciated and utilised so that many feel their career is less interesting than they had anticipated.
There are about 38,000 active GPs in Australia poorly distributed in terms of equity of access for many Australians. This is especially true for rural communities where there is need for at least 2000 more GPs today. With interest in the speciality waning we estimate a shortfall of 11,000 GPs by the end of the decade.
Bulk billing is collapsing. This is inescapable as so many GP practices are looking at financial ruin. As many as 10% of the GP work force is employed by corporations many of which are struggling to avoid bankruptcy. We are all going to pay more for GP services. Australians already suffer 30 billion dollars worth of out of pocket expenses for the health care they need in a country that claims to provide universal health insurance. The need for a total restructure of Primary Care is more obvious than ever.
So what’s to be done?
Before discussing a new model for Primary Care there are significant issues/problems that we need to consider as they must be addressed by our new model.
Health is profitable so investing in health maintenance is a good business deal. Sickness is very expensive and it is sickness in the form of chronic illness that consumes the vast majority of our health expenditure and the time of our GPs. Much of the illness that reduces the quality of life for so many of us is avoidable. 50% of us by the age of 50 have at least one chronic illness and are likely to develop another.
Looking at international comparisons for a population’s health literacy we find ourselves at the bottom of the list among developed countries. Only 40% of Australians have adequate health literacy defined as the possession of essential knowledge about their bodies, health maintenance and a capacity to efficiently navigate the health care system.
There is a strong evidence base for the rewards we would reap if we abandoned our doctor and illness centric system for one where a range of different health professionals (“Team Medicine”) is available to help us stay well and better care for those who are ill. The co-location of the members of the team in the one physical setting providing one’s “ Medical Home” provides enormous advantages for patients.
The Medical Home model provides health education, continuity of care, early diagnosis of problems that if not treated clearly could become chronic and serious, team management from the one site of the complex needs of those with chronic illness and extension of care for those enrolled into their community setting.
I spent my clinical career in major public hospitals often caring for very sick patients. When I visited my patients I was accompanied by members of the ward based team whose insights into my patients progress or lack thereof was so important. After a ward round the team would sit down in a conference room and discuss ongoing management strategies. This multi-disciplinary input into a management plan wasn essential for the excellence we hoped to achieve.All involved were salaried professionals funded by NSW Health. The principles involved need to be applied to Primary care by establishing community based “Medical Homes”.
Such a model would involve clinicians from one’s ‘Medical Home’ extending care for those enrolled into community settings. Year after year statisticians tell us that some 650,000 admissions to our overstretched public hospitals could be avoided with an effective community intervention in the three weeks before hospital admission was unavoidable. Average cost of an admission to a public hospital? About $6000.
The ‘Holy Grail’ for Primary Care in Australia will feature Medicare funding such a system.
Recently I had the pleasure of discussing the necessary restructuring of our health system with more than 200 nurses enrolled in the School of Nursing at Sydney University. As is true at many universities now, they have been prepared for a clinical life involving “Team Medicine” the course involves inter-professional learning with students from other clinical disciplines. They look forward to working in a Medical Home program but wonder if jobs in such a setting will be available!
In part two of this discussion we can discuss the journey that we will need to take to reach such a destination.