One of the authors was recently asked to be part of a panel for a discussion whose title was “Funding models for primary health: evolution not revolution” and where one of the questions asked (in advance to be fair) was “How far did I think we should go on funding alterations to optimise the scope of practice changes that have been proposed, without upsetting too many interest groups to the point where it becomes unproductive for all parties?”

No, really, that was the question. So which interest groups, we wondered, might the panel host have had in mind? We thought for starters that this paper needed to rebut the proposal that we even need to focus on avoidance of upsetting an interest group, unless of course that interest group was our health consumers.

We have had a series of reviews of primary healthcare including the “ Scope of Practice Review” which, to quote the Department of Health and Aged Care “explored the system changes and practical improvements needed to support greater productivity and improved, safe and affordable care for patients”. The Department website goes on to say, “with the right technology, innovation and regulation in place, the healthcare system can gain the full benefit of professional skills and expertise”.

Which seems to suggest that, at this moment in history, the healthcare system doesn’t gain the full benefit of professional skills and expertise. And yet we know that the staff working in PHC are available, no, even willing and able, to offer the full benefit of their professional skills and expertise. Clearly, there is an appetite for action within the Department, with Blair Comley making the point that “the work of the first term gives a strong foundation of robust information, a strong mandate for reform, and the time has come to deliver on priority commitments.”

And yet, at this time, many of the old tropes continue. The approach to PHC is still general practitioners first, then everyone else might get a bite of what’s left over (if anything). For example, the _Operational Guidance for Urgent Care Clinics_, mandates a GP-led model of care. Despite referencing flexible workforce models, the Guidance and funding contracts explicitly stipulate that nurse practitioners may only provide care under the physical supervision of a doctor, which does not reflect the recognised NP scope of practice. Nor does it align with the NP Workforce Plan, to which the government has committed more than $100 million in order to “support nurse practitioners to deliver health and aged care services. The plan addresses barriers that have prevented them from working to their full potential”.

If we are to achieve many of the reforms recommended from all the reviews during Labor’s first term in office, then the weight of outcome evidence supports funding across the multidisciplinary team. The government needs to articulate a clear vision for the primary health system, how it would work to benefit Australians and how the MDTs can work towards that, rather than seeing the medical lobby groups fighting and resisting each incremental change (eg increase to workforce incentive payments or add a new Medicare benefits schedule item number or increase the value of MBS item numbers to other healthcare practitioners, one item at a time.

The current change to chronic disease management items is a classic case in point. The GP lobby groups insist that chronic disease management is a key part of their work. However, only ~20% of Chronic Disease Care Plans are being followed up (and often by the practice nurses). It is important to recognise that blended funding models (that recognise the work of the individual who is directing/co-ordinating the patient’s care) are needed to assure the survival of taxpayer subsidised healthcare in Australia. A workforce that works to the fullest extent of their scope of practice is a welcome outcome of health system financing reform. We propose that only 30% of health funding should go towards funding fee for service health services, but the remaining health funding should be apportioned to enabling team-based care.

Another example of the government continuing to stifle innovation is in the 12-month rule for telehealth services. Telehealth services are popular precisely because there is an unmet need in accessibility of timely and affordable healthcare, which is being met in some instances by telehealth services. This is an example of disruptive innovation within the health system as mainstream healthcare did not meet the needs of individuals. There have been several attempts to modernise general practice over the past 10 years, including significant investment into telehealth services that largely weren’t taken up by general practices, despite numerous infrastructure grants and funding strategies to allow for this.

However, there were funding barriers for mainstream NP care through the Commonwealth, as well as outdated and patriarchal views on the NP role as seen through medical lobby groups, that saw their active exclusion from general practice. Such obstacles meant that NPs picked up the baton to provide telehealth services as a routine part of their care in many private sector NP organisations, even before the advent of COVID. This was viewed as destabilising general practice, so the government introduced new restrictions to NP services.

The government needs to look at its policy settings. It is investing in growing the NP workforce, but it isn’t valuing NPs, so they are heading for these newer business models. It is also spending money on developing this workforce and enabling “full scope of practice”, while continuing to undervalue NPs. The private sector is valuing NPs more highly than MBS-funded general practices, so many of them are working for telehealth-only services. These business models are responding to the market being created by the government. The Commonwealth needs to get the funding and policy settings right to ensure the growing NP workforce ends up in the places where we know they can have the biggest impact, and that is in PHC, without restrictions to their scope.

Yet another problem with the current approach to funding is that it only recognises general practices as mymedicare homes, where patients can register voluntarily and thus care can be funded. NP services typically provide services to marginalised populations that GPs do not regularly care for. For example, many NPs work with people with HIV, Hep B, C and trans folk, yet these NP services cannot be recognised as mymedicare homes and therefore cannot be funded. It would make sense for government to acknowledge market failure eg none or not enough service for a local population. Where market failure exists, we need alternative entry points into the health system for Australians. Another example would be when a GP leaves a country town, the current funding models wouldn’t enable the remaining nurse/receptionist/allied health professional to maintain a clinic. If the funding model could flex to provide income to maintain the local team in place, that would provide a better health outcome for the community.

Finally, we need a funding paradigm that acknowledges the government shouldn’t prop up failing business models. If a GP has a poor business model, the government shouldn’t continue to fund it unquestioningly. Stephen Duckett once remarked, “We get the healthcare system that we pay for." Because we are not funding the health that people want, disruptive innovation is occurring, and care is being delivered in new and innovative ways. If the government wants to control this area of healthcare, they need to help fund it, not to stifle it. This would give the leverage the government has to ensure care is provided to a standard and not off the reservation.

But instead, we have a system where access to the government’s regulated and funded healthcare system is controlled by two primary gatekeepers – the over-run and broken state health system and GPs who are fragmented, expensive and unobtainable in many parts of Australia. Any notion of reform to this is held up by lobby groups who want nothing to change, lest it shift the power balance, so we end up with a failed market — as pointed out earlier — that needs disruption, which is occurring. Innovation at present is akin to Henry Ford saying we do not a need a horseless carriage, we simply need a faster, more expensive horse. Now is the time to make bold changes, at the beginning of a second term. Together, nurses and midwives make up 54% of Australia’s health workforce. However, this is not reflected in its representation at the decision-making table which usually bears little resemblance to that of the PHC health workforce! Evolution to date (heavily influenced) has led to an unwieldly and complex system that sees the most vulnerable still unable to access healthcare. We must address how much funding is being wasted in low value care. We cannot keep ignoring it. We need a revolution in PHC funding, not evolution.

The views expressed in this article may or may not reflect those of Pearls and Irritations.