“The implementation of primary health care (PHC) may well be one of the most significant systemic and ideological health reforms of modern times. Countries with stronger PHC systems have demonstrably more efficient, effective, and equitable health care. Primary health care can be considered a philosophy, an approach to the delivery and development of services and first contact health services. It is based on a social, rather than biomedical, model of health, with accessibility to and affordability of service as primary objectives.”

That is the powerful opening statement to a new systematic review investigating what are the core primary health care services that Australians living in rural and remote areas should be able to access.

Thanks to one of the researchers, Associate Professor Tim Carey, for reporting on the findings (which you can also read in full in BMC Health Services Research).

The review raises the tantalising question: if these core services can be identified, will this provide some obligation on funders to ensure they are available and accessible?

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What primary health care services should residents of rural and remote Australia be able to access?

Tim Carey writes:

The disparity in health outcomes between rural and remote Australians compared to their metropolitan counterparts is well established.

One way of helping to reduce this disparity is to have a clear idea of those primary care services that should be considered “core” or essential to any health service regardless of locality.

In metropolitan areas where a wide range of services is readily available, demarcating core services might not be necessary. In rural and remote places, however, where populations are dispersed, what services are most essential and how those services should be delivered are issues of fundamental importance.

A systematic review was undertaken to identify the services that could reasonably be considered “core”. That is, we wanted to find out what the essential package of primary care services were that any Australian, regardless of geography, had a right to expect access to.

We were also interested in understanding the methodology by which any particular researcher or research group arrived at a selection of core services.

The results surprised us.

Despite searching established databases as well as relevant websites and also contacting national and international experts, we could find no readily agreed set of core services.  Indeed, in some places like the UK and New Zealand, it appeared that governments had explicitly avoided defining core services.

Perhaps there are important fiscal implications for articulating a suite of core services: once the core services are identified there is then an obligation to ensure access to these services is efficient and straightforward for all.

Just as there was no readily defined set of core or essential services, there was also no common methodology. The methodologies varied, as did the purposes for which these methodologies were employed.

Terms also varied. In some instances, for example, the terms “functions” and “services” seemed to be used interchangeably. The marked variability in purposes and methodology meant that services as diverse as “water and sanitation” and “microscopic examination of urine” were captured in our review.

Without consensus in the literature to guide us, we synthesised the results by generating a matrix outlining the possible dimensions of primary care services and the demarcations within these dimensions.

One dimension, for example, was “Function of service” with the demarcations “getting people better” and “keeping people well”. Another dimension was “Aspect of body” with the demarcations “physical”, “mental”, and “dental”.

The matrix could be useful in different ways. The matrix could be used, for example, to assess the current service provision in a locality. It could also be used to plan required services in the future. After a reorganisation of services the matrix could also be used to help evaluate service provision.

With the matrix, service planners, health managers, and policy makers might be able to work more closely with communities to make sure that communities are receiving the necessary services in a way that is efficient and effective.

As a consequence, we may begin to see a reduction in the current separation of health outcomes between Australian citizens who live in metropolitan centres and those who reside in rural and remote locations.

•  Tim Carey is Deputy Director, Head of Research at the Centre for Remote Health, a joint centre of Flinders University and Charles Darwin University, and holds positions with the Central Australian Mental Health Service and Centre of Research Excellence in Rural and Remote Primary Health Care

• “What primary health care services should residents of rural and remote Australia be able to access? A systematic review of “core” primary health care services”, by Tim Carey, John Wakerman, John Humphreys, Penny Buykx and Melissa Lindeman.  http://www.biomedcentral.com/1472-6963/13/178/abstract

Raise taxation generally (plus specific hikes for tobacco, alcohol, and unhealthy foods), and remove subsidies on the use of fossil fuels. These are among the suggestions from Croakey contributors outlined in the post below.

Contributors also said they’d like to see the Budget bring increased payments to single parents and the unemployed, as a way of reducing health inequalities.

Another suggestion for addressing heath inequalities was to “publish the taxable income and tax paid by all Australian citizens”.

There is also support for having all Government policy and program decisions subjected to Climate Impact Assessment and Health Impact Assessment.

Reflecting widespread support for a health in all policies approach, one contributor suggested that health-based key performance indicators could be introduced for all portfolios.

Croakey contributors also hope the Budget will show a commitment to ongoing health reform, including a “transition away from the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care”.

As for how the Government could make savings in health – scrap the private health insurance rebate altogether was the suggestion from some.

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For the compilation post below, Croakey contributors were asked:

1. What is the single most important thing the government could do in the health budget to improve population health?

2. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to improve population health?

3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

4. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to tackle health inequalities?

5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

6. Where could savings be made in the health portfolio?

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1. What is the single most important thing the government could do in the health budget to improve population health?

Vern Hughes, National Campaign for Consumer-Centred Health Care
Both Labor and Liberal Parties are reliant on corporate donations from alcohol and gaming companies, and in the Liberal Party’s case, tobacco companies as well.

A ban on political donations by corporates to political parties, allowing only donations from individuals, would sever the financial relationship between these parties and the principal suppliers of products harmful to population health. A disinterested policy discussion would then become possible about how to reduce the impacts of these products.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Reduce the deficit by putting a tax on high salt/fat foods.

Professor Mike Daube, Public Health Advocacy Institute WA
Increase tobacco tax – reduces smoking, reduces inequalities, improves health, provides funding for health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Put money into strengthening population health expertise in Medicare Locals.

Lyn Morgain, Gail O’Donnell of Healthwest Partnership
Increase funding for evidence based work through the Australian National Preventive Health Agency which will focus effort on both national as well as local / regional campaigns that target particular issues / risk factors in local communities / population groups. Ensure the ANPHA focuses on the community and population level.

Flexibility to deliver different interventions / approaches depending on local priorities to support improved outcomes for local communities.

Reference: Dr Fran Baum is Professor of Public Health at Flinders University. At the Senate Inquiry on the Social Determinants of Health Dr Baum commented:

“while the preventative health agenda does attempt to focus on the causes of disease it is limited by the absence of a national agenda devising strategies to address social determinants of health in a systemic way. The predominant focus on individual ‘lifestyle choices’ and behaviour change as the target of interventions does not adequately address the social context in which behaviours occur, or give sufficient emphasis to the role of health promotion strategies focused on creating healthy settings and development of healthy communities.”

Professor Sabina Knight, Director of the Mt Isa Centre for Rural and Remote Health
Strengthen the critical architecture for reform – the Australian National Preventive Health Agency, The Australian Commission on Safety and Quality in Health Care, Health Workforce Australia Independent Hospital Pricing Authority, National Health Performance Authority

Luke van der Beeke, Managing Director, Marketing for Change
The government needs to ensure that the money available is spent effectively.  That means switching to measuring outcomes, not outputs. I’m a big advocate for policy before politics.

Set some tough outcomes and reach for them.  Don’t set easy to achieve outputs that mean nothing in terms of population health.  For example, let’s take health communications.  You can spend $10m or $20m on a shock campaign on obesity, but if you aren’t changing people’s eating habits its all a complete waste of money. So while I think more money is needed for prevention, the most important thing they can do is ensure the money that’s allocated is used effectively.

And a quick point on social marketing.  The Federal Government talk about social marketing, but they’re not really doing social marketing. They  (and the States) are outsourcing to NGOs or big agencies that are delivering health communication campaigns that look great but change very little.

Success is getting measured by outputs that rarely relate to individual behaviours.  All too often, “success” and the associated measures are about being seen to be doing something rather than ACTUALLY doing something. We need behaviour change. And for that you need real social marketing.

Heather Yeatman, president, Public Health Association of Australia
Funding the development of a National Public Health Policy.

Lewis Kaplan CEO General Practice NSW
Fulfil its commitment to the nation’s health rather than just to the Department of Health and Ageing’s budget and invest in substantial and realistically long-term prevention programs (e.g. diabetes), even if the eventual ‘savings’ accrue to state health departments.

Anonymous medico
Improve vaccination coverage. Serious adverse events are rare, but there should be compensation for any child who has a proven disability because of vaccination. Parents are helping the community by having their children immunised, so the community should provide support if there is a problem. The Disability Care (NDIS) could be the appropriate mechanism.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
The Government has to commit to root and branch reform of Medicare. As numerous independent reports in the past few years have pointed to, the most recent from Centre for Independent Studies and CEDA, Medicare is unsustainable and delivering poor quality care for many, many Australians.

This reform must address map-distribution of providers, access to care, cost of care, quality of care. We must begin to transition away form the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care.

Terry Slevin, Cancer Council WA
Expand the National Bowel Cancer Screening program to include a greater number of ages being invited to screen.

Currently with only people turning 50, 55, and 65 being invited, we are missing a rolled gold proven method of reducing deaths from colorectal cancer.  We are also ignoring opportunity to save costs as treating more advanced stage disease is not only less successful but more expensive.

The other thing that is desperately needed is to allow funds to promote the program.  With current participation rates at around 40%, a meaningful investment in an effort to “sell” the benefits of participation would certainly increase participation and therefore the health benefits that are proven to accrue from doing so.

Another is a very modest investment in skin cancer prevention programs. Again another money saver with cost of treatment of preventable skin cancer exceeding the billion dollar mark, here is a case of an ounce of prevention saving pounds (and dollars) of cure.

Linda Shields, professor of nursing – tropical health, James Cook University
Stop thinking that “primary health care” is all about GP clinics. It’s not – it’s about prevention and stopping people getting sick in the first place. Investment in primary healthcare (the real one) would improve the health of all and reduce expensive inpatient costs.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
The secure funding for preventive services.  There is a big problem here in South Australia, and elsewhere, whereby State governments are focusing their sole attention on acute services and assuming/hoping the Federal government will pick up the costs and mantle of preventive services.

This does not seem to be happening – it’s ‘hoped’ that Medicare Locals will pick up these services, but it doesn’t really seem to be their job either.  If we continue with this extremely shorted-sighted view, we are putting the future health of generations in danger.

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2. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to improve population health?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
For the long term, address climate change by removing the subsidies on the use of fossil fuels.

Professor Mike Daube, Public Health Advocacy Institute WA
Sort out the shambolic alcohol tax system – especially abolishing the Wine Equalisation tax (WET) that enables wine to be sold cheaper than bottled water. Again reduces harms, protects the vulnerable, raises money for other health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Increase taxation.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Ensure that the universal nature of Medicare is not undermined by need for increased co-payments, shifts of responsibility for core services to private sector.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
A comprehensive early childhood strategy, education funding and education system reform (as per Gonski recommendations). Increasing social benefits for unemployed people and single parents.

There has been significant progress in using health impact assessments to understand the effect of program and policy changes across Government on the health system and service costs. This means that a reduction or increase in effort in one part of government / community is understood for the impact that it will have on the broader service and support system. This ‘health in all policies’ approach is the best way to understand the true cost and achieve efficiency in the primary care space and allow a more rigorous approach to policy consideration and program development.

A commitment to the recommendations of the Senate Committee inquiry into the Social Determinants of Health.

Luke van der Beeke, Managing Director, Marketing for Change
Health in All Policies is without a doubt the most important thing the government can do to improve population health.  At present government departments work in silos.

Why not introduce health-based KPI’s for all portfolios?  All of them have significant direct or indirect impacts on population health.  There needs to be a shift in the way we think and talk about health in Australia.

There needs to be a shift in the way we think and talk about health in Australia, and most importantly, a change to WHO talks about health in Australia.  If health practitioners and experts are the only ones talking about health we will never fix public health.

Associate Professor Heather Yeatman, president PHAA
The establishment of an Australian Centre for Disease Control (ACDC).  As a first step the Government must to commission a study to examine the benefits and costs of establishing an ACDC.

The establishment of and requirement for a Climate Impact Assessment and Health Impact Assessment to accompany all Government policy and program decisions (in a similar way to the current requirement for Regulatory Impact Assessments).

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Maintain investment in smoking cessation and mental health and well-being.

Lewis Kaplan, CEO General Practice NSW
Make health in all policies a requirement across all portfolios – eg South Australia.

Anonymous medico
We spend $billions treating diseases resulting from people’s lifestyle choices. While a fat tax would probably be difficult to implement, alcohol is still far too cheap.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Slash the size of the Federal Bureaucracy. Since 2004, an additional 40,000 people have been employed in the APS. This does not include those now employed in organisations like Medicare Locals. Only about 1 in 4 of the APS actually deliver an end service. The duplication of project management, the inefficiency of the APS has become a high cost factor.

The Federal Government should literally get out of the business of delivering services. It should focus on policy development and setting parameters for delivery.

Second they must wind back all middle class welfare and industry welfare – this adds tens of billions to our nations taxation system.

Linda Shields, professor of nursing – tropical health, James Cook University
Preventing illness in the first place would save heaps of money down the track. A very good investment.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To work on joined-up government to tackle the social determinants of health.  There is evidence globally, and locally, of the benefits of Health in All Policies in terms of illness prevention, health promotion and overall health gains.

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3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

Vern Hughes, National Campaign for Consumer-Centred Health Care
There is no quick fix for health inequalities, which are a product of social and economic well-being. The single most useful thing the government can do in the health debate is state this publicly.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Improve the Newstart payment.

Associate Professor Mark Wenitong, Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences, 
James Cook University, Cairns
Understanding the synergies between health and social portfolios re Aboriginal and Torres Strait Islander health inequalities, and thinking about “bundling” program funding (across FACSIA/DOHA eg) to address early childhood/family functioning support and health in a prevention sense.

We also need to have a more sophisticated understanding of health $ investment for long-term health outcomes vs GFC pushed “corporate health” approaches to efficiency.

We need to measure efficiency against a human capability framework, rather than “efficiency” driven by the accountancy consultants (ie KPMG PwC E&Y etc that are basically accountants, hence an inbuilt bias towards fiscal efficiency) – that do ALL of the scoping for DoHA.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Provision of funding through improved local service delivery to target populations and geographies where particularly poor health outcomes exist.  A move away from waiting until an acute service response is required (surgery or emergency department) and towards community based primary care.

Targeting intergenerational poverty through a focus on child health.  A comprehensive early childhood health and wellbeing strategy combined with a social protection system would be a positive step towards addressing social and health inequalities.

Luke van der Beeke Managing Director, Marketing for Change
To tackle any issue it needs to be taken seriously.  The Federal government needs to commit to action on tackling health inequalities.

Associate Professor Heather Yeatman, president PHAA
Invest in building the competence and capacity of a national preventative health workforce who understand inequity and the social and economic determinants of health and are skilled to effectively deliver preventive health services at the local level.

Maintaining the funding of Medicare Locals, Locals and Women’s Health at a level that will allow comprehensive primary healthcare based on an understanding of the social determinants of health.

Retain and extend funding for the “Close the Gap” measures including additional support for Aboriginal Medical Services and Aboriginal Health Services.

Develop a National Aboriginal and Torres Strait Islander Social Determinants of Health Policy as a key strategy in closing the gap and overcoming Indigenous disadvantage. The policy needs to describe the social determinants, focus on social inclusion and support the provision of real opportunities in education, employment and health status, with funding tied to delivery of outcomes.  While retaining current levels and build in future growth of funding for the “Close the Gap” measures.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE) 
Ensure access to high quality services for all Australians irrespective of who they are and where they live.

Lewis Kaplan CEO General Practice NSW
Make the social determinants of health the primary driver of health budget allocations.

Anonymous medico
Many inequalities result from poor access to services. There should be more incentives to get health professionals into areas of need.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Transition away from fee-for-service asap.

Linda Shields, professor of nursing – tropical health, James Cook University
Same thing. If primary health care programmes targeted at the disadvantaged were supported, then the gaps would begin to close.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to the Australian National Preventive Health Agency agenda – philosophically, financially and in terms of services and systems.

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4. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to tackle health inequalities?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Publish the taxable income and tax paid by all Australian citizens.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Raise the dole.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
To look at health in the broadest sense and understand the economic and social benefits of health improvement and prevention activities.  But this requires more than one activity.

For example to ensure the implementation of a comprehensive early years strategy as well as improved funding and reform of the education system to improve outcomes for poor and marginalised communities / individuals; greater access to training and employment opportunities for individuals and communities facing exclusion / disadvantage; commitment to the National Disability Insurance Scheme; funding for public transport in growth corridors; support food security in remote and urban communities; improved access to early intervention community based mental health services; programs that will use the NBN to reduce the digital divide; more secure housing for low income individuals and families.

Further work to reduce income inequality and the experience of poverty is necessary.  This would include reversing the decision to push single mothers onto Newstart and increasing the level of the Newstart allowance.

Associate Professor Heather Yeatman, president PHAA
The PHAA seeks a comprehensive approach to improving health through applying strategies (financial disincentives) known to influence behaviours positively, and at the same time raise funds for initiatives to tackle health inequalities:

TOBACCO REVENUE: Cigarette prices in Australia are lower than in some comparable countries. An increase in excise duty of ten cents per stick would reduce smoking and raise approximately $1.25 billion.

ALCOHOL TAXATION: Projected savings of $849 million if a volumetric tax is applied to wine and the WET rebate abolished.

JUNK FOOD: Implement a tax/levy on selected nutritionally undesirable foods (such as sugary soft drinks), using the funds raised for preventive programs and to promote and subsidise nutritionally desirable foods for disadvantaged groups.

LOWER CARBON USAGE: Build on the range of taxes and revenues so far introduced to lower carbon usage.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Increase Newstart Payments.

Lewis Kaplan CEO General Practice NSW
Create a single, accountable health care and disease prevention system with priority given to primary health care – this would mean educating the public too as to why acute care needs to be re-thought.

Anonymous medico
There is an association between unemployment and ill health. While overall unemployment is reported to be low, there are areas/ages of high unemployment, which should be addressed.

Linda Shields, professor of nursing – tropical health, James Cook University
Make health a federal priority and remove it from the states (yes, I know – hell will freeze over because of states’ rights etc).

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to quality education for all.  The Gonski Review partly deals with this, but it is still my belief that part-funding private education (as the Government does) is drawing money away from services for the most needy children and families.

I cannot understand public subsidizing of private education (or private healthcare for that matter) – if parents want private education for whatever reason, they should pay for it – ALL of it.  They would release public money to do what it’s there for – focus on the public system.

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5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

Vern Hughes, National Campaign for Consumer-Centred Health Care
The big public need is for long-overdue media scrutiny of budgetary handouts to provider interests in health care across private and public sectors, beginning with public funding of provider peak bodies and the role of this public funding in the formation and continuation of provider-centred health policy.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Look at the equity impact of measures; get away from the obsession about having a surplus, please.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Look for investment that will reduce the rate of growth in health spending, rather than perpetuate the sometimes inefficient investment in the acute settings – when early intervention and more coordinated care will result in cheaper and better health outcomes.

Given the political environment and the likely change of Government what is the Opposition’s proposed approach to the infrastructure that has been developed in recent years (Medicare Locals, Australian National Preventive Health Agency, the Organ and Tissue Authority, the Health Workforce Agency, local health networks etc) that seek to improve system planning and performance.  What is their commitment to funding prevention and health promoting work?

Associate Professor Heather Yeatman, president PHAA
Where will the cuts be made in health?

What effort is made to take a LONG TERM VISION?

Is there any attempt to deal with the COST SHIFTING of jurisdictions such as Queensland and South Australia that are removing so much of their prevention and primary care resources and arguing it is the responsibility of the Medicare Locals?

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Establish a ” truthometre” that assessed assertions/ commentary made by all parties for truthfullness and make his transparent and easy to access. (Note from Croakey to readers – see the new PolitiFact initiative).

Lewis Kaplan, CEO General Practice NSW
Stop focussing on hospital waiting lists and address the reason why they exist, which is poorly integrated primary health care and inadequate national prevention programs coupled with inadequate policy on health promotion e.g. alcohol and obesity, exercise and diet.

Anonymous medico
I would like to know about the policies, not the politics!

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6. Where could savings be made in the health portfolio?

Vern Hughes, National Campaign for Consumer-Centred Health Care
A shift from a provider-centred health system to a consumer-centred health system would involve removal of failed service coordination programs that attempt to connect fragmented providers; abolition of Medicare Locals; removal of subsidies to practitioner training programs; removal of capital and block funding grants to hospitals; and removal of public funding of industry peak bodies in public and private sectors.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Remove the subsidy for private health insurance

Associate Professor Mark Wenitong,
 Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences 
James Cook University, Cairns
I think there are real savings to be made in well considered across portfolio strategic program funding to address health inequality, (and CONGRESS/NHLF is the structure to support this from Aboriginal and Torres Strait Islander perspective, and it supports real Aboriginal and Torres Strait Islander leadership).

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Eliminate the private health insurance rebate completely

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
PBS.

Ongoing focus on ensuring that the price that the Australian government pays for both patent protected and generic medicines reflects the international market and that particular points of the delivery system (such as pharmacists) are not achieving reimbursement for services which do not reflect cost of service or a high risk profile.

Health workforce reform.

Focussing health care professionals at the ‘top of their scope of practice’ requires recognition of the diversity of health care roles across the spectrum and also allows care/ interventions to be delivered at the lowest workforce cost. Currently decisions around the location of treatment are based on professional boundaries which were designed over the course of the last century and show little resemblance to either a modern risk / clinical governance approach or indeed any assessment of best outcomes for clients / consumers.

The need for a systems approach that accounts for the linkages between all parts of the service and support systems (regardless of funder) has never been more apparent.  In seeking to promote better health outcomes, increase the effectiveness of services and seek to reduce the rate of growth of health spending this interface is an area that has been consistently overlooked.

There is a growing body of evidence that the single greatest efficiency that could be made to the health budget is to move (where clinically appropriate) from high cost, high tech acute care settings to lower cost, community based primary care.  However despite this knowledge this systems approach continues to be undervalued.

Associate Professor Heather Yeatman, President PHAA
Rather than savings in federal health, we should be looking at the revenue raising side (see question 4).

Associate Professor Jan J Barendregt, School of Population Health, University of Queensland
As we reported in 2010 in our ACE-Prevention results, and in journal articles since, Australia pays far too much for cardiovascular disease prevention, due to a combination of missing out on the most efficient interventions, and paying too much for generic drugs.

Mandatory salt limits in food is very cheap, but is not being pursued.

Pharmac in New Zealand pays only a fraction of what we do for some very much-used generic drugs.

We went out of our way to make these results known in policy-making circles, and are frankly baffled by the complete lack of response. Why do policy makers keep wasting taxpayers’ money while the facts are known to them?

Lewis Kaplan, CEO General Practice NSW
Savings – not this time – it’s critical that the nation invest strongly in its future health via prevention and integrated primary health care or we will go broke.

Anonymous medico
Stop the federal-state cost shifting. Greater use of generic medicines.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
$1billion per annum from reducing DOHA from 6000+ to 600 staff in a policy ministry for starters. Then tackle PBS, MBS issues.

Dr Peter Arnold, retired GP
I have been singing from the same song-book since 1973, when I was so publicly opposed to universal benefits (as being introduced by Medibank) and when I argued unsuccessfully in favour of selective benefits – aimed at those who needed them (pooh-poohed by Bill Hayden and his advisers because people would feel ‘stigmatised’). Today, my attitude has become commonplace, with its own jargon: “middle-class welfare”.

The answer to your question is simple – targeted (selective benefits). Taxpayers should not be funding the health care of the affluent – neither through Medicare nor through government’s propping up of private health funds. You want savings – here they are!

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
Bureaucracy!!!!!!

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BUT…Was Croakey asking the wrong questions?

Ian McAuley, lecturer in public sector financing, Canberra University
I’d find these questions easier to answer if the word “budget” were left out.

The budget is simply a set of appropriation bills.  The policies on which those appropriations should have been developed and articulated over many years.

But the budget has morphed into the major statement of government policy. Fiscal considerations drive policy, rather than the other way around.  Instead of considering what is needed and then finding how these needs can be funded, funding drives policy.  The budgetary process is one in which revenue is taken as a “given”, as are most pensions and other personal transfers, and all program portfolios have to accommodate their programs into what is left over.

Some would say that this leads to worthwhile expenditure restraint. But it also leads to cost shifting.  In health care costs get shifted on to consumers with co-payments and private health insurance is called on to do the a job which taxation and Medicare do much better.

So what would I like to see?  A health policy, rather than a set of fiscal projections. Funding is important, of course, but funding considerations should be about all sources of funding, instead of the current narrow focus on that funding which passes through the budget.

How can we structure co-payments so that they send appropriate price signals without not discouraging useful therapy?  How can we fund private hospitals without having them linked to private insurance?  How can we control the moral hazard which results when services are free at the point of delivery, be that because of Medicare or private insurance?  How can we phase out private health insurance as we have done with other high cost industries such as clothing and footwear?

***

More reading on the Budget and health

• Jennifer Doggett recently compiled this very useful overview of the federal budget submissions from peak health and social welfare group. Increased action on prevention, the social determinants of health, Indigenous health, primary care, and consumer engagement were high on the list of priorities.

• John Menadue suggests tackling increases in medical servicing, especially in pathology and radiology.

• Australian Drug Law Reform Foundation president Dr Alex Wodak suggests better use of the funds currently spent on law enforcement of illicit drugs policy.

• The St Vincent de Paul Society calls for an increase in the Newstart allowance.

With less than a week to go before the Federal Budget 2013, the leaks and rumours (and rumours about leaks) are increasing and speculation about possible new funding measures is mounting. The following analysis looks at the main items on the wish-lists of eight peak health groups and identifies key issues on which there is broad health sector agreement.

An increased focus on prevention and the social determinants of health, more action on Indigenous health and a stronger primary care sector are the main areas of agreement in the Budget wish-lists of key health groups.

Croakey analysed a number of pre-Budget submissions from peak health and social welfare bodies and prepared the following summary of the key proposals from the following groups:  Australian Health Care Reform Alliance (AHCRA); Australian Council of Social Services (ACOSS); Australian Healthcare and Hospitals Association (AHHA); Australian Medicare Locals Alliance (AMLA); Australian Medical Association (AMA); Catholic Health Australia (CHA); Consumers Health Forum of Australia (CHF); and the Public Health Association of Australia (PHAA).  The National Rural Health Alliance was also contacted but did not submit a Budget Submission for this year. It will, however, be providing a response to the Budget once it is brought down next Tuesday.  Links to each organisation’s specific submission/policy document are provided below.

Prevention

A number of groups seek increased funding for prevention. The PHAA wants the level of funding for prevention to rise from 2.2% to 4% of health expenditure.  It is also seeking an investment into building the competence and capacity of a national preventative health workforce who understand inequity and the social and economic determinants of health and are skilled to effectively deliver preventive health services at the local level. CHA, AHCRA and the AMA also support a range of measures to increase the focus on preventative health and health promotion.

Social determinants of Health

The need to focus on the social determinants of health was raised by a number of groups, in particular the AHHA, AHCRA and CHA. Among AHHA’s specific proposals are that the Australian Government make a formal statement of  support for the recommendations of the WHO Commission on Social Determinants of Health and in conjunction with the States,  develop an action plan to implement the recommendations of the WHO Commission  on Social Determinants of Health.  AHHA also supports a federal ‘health in all policies’ approach to policy development and legislation and the establishment of an Australian Commission on the Social Determinants of Health to coordinate interagency action and report annually on progress to  address the social determinants and reduce health inequity.

Indigenous Health

There is strong support among the peak health groups for increased action on Indigenous health with a number of submissions making specific suggestions as to how the ‘health gap’ between Indigenous and non—Indigenous Australians could be reduced. The AHHA recommends that National Indigenous Hospital Demonstration and Mentoring Program be funded that focuses on Indigenous heart health.  The PHAA supports retaining and extending funding for the “Close the Gap” measures including additional support for Aboriginal Medical Services and Aboriginal Health Services; and the AMA wants the Federal Government to renew its commitment to a COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes for a further five years from 2013, with the same level of funding allocation as provided in 2008.

Primary Care

The need for a strong primary care sector was the focus of a number of recommendations with groups expressing support for ongoing funding for Medicare Locals. The PHHA suggests maintaining the funding of Medicare Locals, Locals and Women’s Health at a level that will allow comprehensive primary healthcare based on an understanding of the social determinants of health. CHA recommends a number of strategies for strengthening primary and community care and ACOSS seeks an investment in capacity for community health services to engage with key health policies, including the establishment of Medicare Locals and the Partners in Recovery framework, as a key element of building the role of community health services to help reduce inefficiencies in the health budgets from preventable hospital admissions.

Consumer engagement

Unsurprisingly, consumer engagement was a key focus of CHF’s submission which includes a recommendation that the Government recognise the value of consumer and community participation in health and medical research, and reflects this in the allocation of funding. CHF also wants the Government to commit to funding the development and implementation of measures of health outcomes and consumer experience in the Australian health system that will ultimately lead to a more effective and efficient healthcare system.  Action on out-of-pocket costs for health services is another item on CHF’s agenda, along with a commitment that any Government measures that aim to reduce PBS expenditure do not reduce or delay consumer access to essential medicines.  Increased consumer engagement in the health system is also strongly supported by CHA which proposes a number of strategies to facilitate greater consumer empowerment and engagement. 

Health system issues

Broad health system issues were addressed in a number of submissions, including the AHHA’s which proposes a comprehensive research and evaluation of the National  Health Reforms.   The AHHA is also seeking a National Health System Coordination and Integration Program and a National Discharge Planning and Referral Program. The CHA supports the need for improved integration and transition with a number of proposals to take health care ‘from silos to a system’ and also wants to reform health system governance.

Ambulance Services

Both AHHA and CHF support a national program funded by the Commonwealth to provide universal access to ambulance services for all Australians.

Research and evidence

CHF highlighted the need to increase the evidence base for health care in its submission, including proposing that the Government commits to funding at least a proportion of the costs for the establishment and implementation of clinical registers, following the conclusion of consultations to identify the most appropriate model or models.  It also supported a commitment to funding the implementation of the recommendations of the McKeon Review.

Chronic disease

A new approach to chronic disease management was proposed by AMLA involving Medicare Locals implementing a national network of chronic disease care coordinators to help people with chronic disease to access tailored prevention and/or management programs and to establish local health provider networks to ensure better access to the multidisciplinary care required for this. In contrast, CHF focussed on a different approach to chronic disease management suggesting that the Government fund a pilot of personal health budgets for people with chronic and complex conditions, with a view to widespread implementation.

Early childhood

Early childhood development was a key focus of the AMLA submission with a comprehensive proposal for Medicare Locals to work in partnership with relevant agencies to develop early childhood ‘masterplans’ for each ML community. The initiative would draw on the Partners in Recovery (PIR) model to develop and implement pathways that link multi-sectoral services to systematically address early childhood outcomes.  

Oral health

The AHHA submission recognises the funding already allocated to public dental services and recommends that this be built on with additional funding, in order to establish a Universal Oral and Dental Health Scheme for all Australians within five year

Workforce

The AHHA and the AMA both focussed on workforce issues in their submissions. The AHHA is seeking an evidence based graduate nurse program for all nurses in Australia. This would include a national Nurse Graduate Support Teams program to provide for all new graduates to have access to a team dedicated to supporting them as they begin their career. The AHHA also is proposing an innovative program for supporting the employment of refugees and migrants in health services. This would provide benefits to the individual as it facilitates social inclusion and social cohesion and also to health services which would be able to fill skill and labour shortages and develop staff profiles that reflect the cultural diversity of the wider community. In contrast the AMA is requesting increases in GP and specialist training places and funded intern places in private hospitals. It also wants to increase the payment to GPs of teaching medical students.

Non-health measures

ACOSS focussed on a range of non-health measures, including raising the level of payments for Newstart Allowance, Youth Allowance and other Allowance payments for single adults and young people living independently of their parents; doubling the number of wage subsidies available for very long term unemployed people to 20,000 places per year and substantially boosting the resources available to Job Service Australia providers to work intensively with this group from present inadequate levels. It also proposed establishing an Affordable Housing Growth Fund to expand the stock of affordable housing and investing in the capacity of the community sector to deliver services and engage in national industry initiatives. 

Savings measures

Many of the submissions included suggestions for funding the new initiatives proposed. These included the PHAA’s proposals to increase excise duty by ten cents per cigarette and introduce a volumetric tax for wine (an abolition of the current WET rebate). PHAA also suggested a new tax/levy on selected nutritionally undesirable foods.   ACOSS suggested  a removal of both the 30% private health insurance rebate for ancillary cover and the Medical Expenses Tax Offset.

Submissions

The following are links to the submissions from each group – in some cases groups provided a recent policy document to Government in lieu of a forma Budget submission.

Australian Health Care Reform Alliance

Australian Council of Social Services

Australian Healthcare and Hospitals Association

Australian Medicare Locals Alliance

Australian Medical Association

Catholic Health Australia

Consumers Health Forum of Australia

Public Health Association of Australia

Teachers aren’t paid a fee for each lesson they teach, nor are police officers paid for each arrest they make. Doctors, on the other hand, are paid for each patient they see. This funding model is the basis of Medicare, the main funder of out-of-hospital care across the country.

Medicare is largely a “fee-for-service” system. This has the benefits of simplicity and ease of administration: doctor sees patient, doctor collects fee. But the simplicity can also be a disadvantage for such a complex and multidimensional process as health care.

In 2010–11, Medicare Australia paid benefits of A$16.4 billion(up from A$10.9 billion in 2005-6), but taxation revenue from the Medicare Levy (including the Medicare Levy Surcharge) was only A$8.3 billion. So Medicare is a drain on government finances and there is increasing pressure to contain costs.

Fee-for-service pitfalls

The main issue with a fee-for-service system is defining what constitutes a “service”. For primary care, that usually means a level B consultation, where the GP sees the patient for up to 20 minutes. The GP receives A$36.30 from Medicare and can also charge the patient a co-payment.

This definition of a service automatically gives GPs incentives to see more patients and recommend follow-up appointments rather than provide long consultations to patients with multiple health conditions.

Anybody who’s been to an inner city 100% bulk-billing clinic will probably be familiar with what’s known as “six-minute medicine”. You barely sit down in the consulting room and tell the doctor what’s wrong before being ushered out, script or referral in hand. This phenomenon demonstrates the financial incentives of a fee-for-service system at its worst.

The dominance of fee-for-service medicine also inhibits team work in primary care, or task delegation, particularly between GPs and other health-care professionals such as nurses.

Practice nurses can play an important role in managing health conditions of the most complex and needy patients, such as those with diabetes or cancer. And employing more practice nurses can save expensive GPs from conducting routine vaccinations and cervical screening procedures.

But some GPs are reluctant to hire practice nurses, preferring to instead provide these services and receive the government rebates. As a result, Australia has just one practice nurse for every three GPs, compared with one nurse for every two GPs in the United Kingdom.

The fee-for-service system causes problems for both cost containment and quality of care – it’s certainly ripe for reform.

A better alternative?

The primary alternative to fee-for-service is capitation. This system involves paying doctors an annual fee for each patient they have enrolled in their practice. The payment is in return for the GP “looking after” that patient for the whole year.

So GPs do not receive more money for seeing their patients more often, and indeed will benefit from lower costs themselves if patient health improves and they require less care in the future.

Capitation has been the primary funding method for general practice in the United Kingdom for more than 100 years, and despite recent policy reforms to introduce performance payments, it remains the source of the majority of GPs’ revenue.

More recent examples of capitation come from North America. First is the growth of managed care in the United States, where capitation has been widely used, with the primary motivation of constraining costs.

A second example is in Canada, and the province of Ontario in particular, where voluntary adoption of capitation by GPs has become increasingly popular over the past decade. Policymakers there see the main benefits of capitation as increased quality of care through team work and stable, controllable costs.

Sounds great so far? Well, there are some downsides. For capitation to work, patients have to be enrolled in only one practice – say goodbye to the convenience of visiting one doctor near your workplace and one near home.

Also, the annual payments need to be adjusted to meet the needs of enrolled populations (which means more capitation money for enrolling older, sicker patients).

The road to reform

While all health-care financing methods have disadvantages, to me the upsides of capitation outweigh the downsides. Having said that, a new payment system for doctors in Australia cannot be adopted overnight.

A voluntary scheme that gives GPs the option to enrol some patients and receive (initially small) capitation payments alongside their Medicare rebates, would be a good place to start. The fee-for-service system could be slowly phased out by freezing rebate levels so they become less valuable in real terms over time. Concurrently, capitation payments could be gradually increased to make them more attractive.

Capitation also has the advantage of working well alongside pay-for-performance schemes such as the Quality and Outcomes Framework in the UK. Indeed, the current Diabetes Care Project being run as a pilot scheme by the Australian Department of Health and Ageing, uses enrolment and capitation payments alongside performance pay to try and improve care for diabetes patients.

Perhaps the results of the trial will shed some light on the potential benefits of capitation payment for Australian GPs more widely. But we’ll have to wait – the project won’t begin itsevaluation phase until early next year.

** Peter Sivey is a Senior Research Fellow of Health Economics at the Melbourne Institute of Applied Economic and Social Research at the University of Melbourne. He receives funding from the Australian Research Council, the National Health and Medical Research Council and the Victorian Department of Health. 

This article was originally published on The Conversation and is  the fourth part of a series on Health Rationing, which examines Australia’s rising health costs and the tough decisions governments must make to rein them it. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

While the federal election is still months away, issues of health funding are already dominating the news. A Grattan Institute report released yesterday, for instance, noted the greatest budgetary pressure facing Australia comes from sustained increases in health costs.

Last night, ABC TV’s Q&A featured Health Minister Tanya Plibersek and Shadow Health Minister Peter Dutton who faced up to questions from the audience with the knowledge that their responses must win over voters in this election year.

They were questioned a range of health issues – from hospital funding and health workforce training to organ donation and end-of-life care. We’ve asked our experts to assess their performance.

Hospital funding “blame game”

Stephen Duckett: Health policy in Australia is often seen through the lens of Commonwealth-state relations so it was no surprise that the first question on Q&A was about the funding “blame game”. There was no real answer from either Minister Tanya Plibersek or Shadow Minister Peter Dutton, but then again, what could they say? I’m not going to hold states to account? Things will always be sweetness and light between me and my state colleagues? Yeah, right!

Certainly Commonwealth Treasury got it wrong last year in the way they indexed state health grants, but I think they’ve learnt their lesson and probably won’t do that again.

Commonwealth-state issues will continue while there are unclear or inappropriate dividing lines between state and Commonwealth responsibilities. The new hospital funding arrangements, to kick in 1 July 2014, are an improvement but other problem areas (health professional training, for instance) remain.

Privatised public hospitals

Elizabeth Savage: The Productivity Commission found no efficiency advantages for the private hospital system compared with the public system. Even within public hospitals in New South Wales, there is evidence that higher income patient groups and private patients are advantaged in accessing elective procedures.

One motivation for this is the extra revenue hospitals receive from private patients. If public hospitals were fully privately managed, there is considerable risk that access will depend much more strongly on ability to pay.

Health cost blowout

Hal Swerissen: The government is pinning its hopes on reforms like the national introduction of activity-based funding for hospitals, the introduction of local hospital networks and Medicare Locals. The Opposition supports activity-based funding and some form of local coordination, but isn’t convinced the current organisation is right.

It criticises the inefficiency of additional layers of coordination as waste, putting its emphasis on the delivery of frontline services. The government continues to blame the states for reductions in funding for their hospital systems and, at least in Victoria, will consider bypassing them and to fund individual hospitals for the services they provide.

Palliative care

Kenneth Hillman: Neither answered the question on palliative care well, or with vision. Perhaps the phrase end-of-life care is more appropriate as palliative care is a medical speciality with a narrow interpretation of how, not only our health service is to respond to the tsunami of aged people needing high level care towards the end of their lives, but also how we mobilise the resources of many other services in our community.

We also need to begin an open discourse about ageing, dying and death and how our society wants it managed. And what we are prepared to sacrifice in order to fund it.

As someone who works in the high-technology and high-cost end of hospital medicine, I can see there are enormous savings if we can arrange more appropriate care for people at the end of their life. Instead of what we do at the moment, which is treat the majority of them in acute hospitals.

It’s not necessarily what our society wants and is a large contributor to the unsustainable costs of health care. It requires vision; de-medicalisation of the ageing and dying process; working across all sectors and engaging with our society as we go about it.

Organ donation

Holly Northam: The responsibility rests with the hospital to expertly identify the wishes of the deceased, using all available forms of evidence (such as the organ donor register) and ensure the family are given the support they need to agree to donation. Very few families override the wishes of the deceased if they are known.

Australia should be able to have an 85% consent rate, not the approximately 58% it has at present. The only place for opt-out legislation is to give legal support to medical staff to intervene with the use of organ sustaining technology when a patient is on the point of death.This would also help make the coroner accountable for refusals to allow organ donation to proceed.

GP income, health professional training and Medicare Locals

James Gillespie: The discussion got off on a bad foot with a rather partisan diatribe on class war and GP salaries. This let both the minister and shadow minister off the hook, with no need to explain how the system will handle the large generational change in general practice over the next decade or so.

The flood of new graduates offers some real opportunities to devise better ways of collaborative working across professions and parts of the health system.

Both speakers did make gestures towards improving the integration of primary care and hospital services. Neither went much beyond generalities. But it was good to see that Dutton’s promise to abolish Medicare Locals is getting vaguer each time the question is raised. He is also accepting that many are doing a good and innovative job.

These organisations have been running for less than two years – the majority for even less than that – so it is far too early to make any definitive judgements. The last thing that the health system needs is another major reorganisation.

Peter Broooks: The discussion was very focused on doctors – what about all the other health professionals who assist and work as part of a coordinated team. With the burgeoning costs, we really do need to stop focusing on hospital beds and develop ways of caring for patients in the community.

Health Workforce Australia predicts a surplus of doctors by 2025 (if we build in a productivity gain) and not a deficit. Training should be taking place in the private sector and in primary care and should be funded appropriately.

Training might also be shortened – particularly for some of the specialities – with partnerships between universities and the colleges. Not too much real innovation from either side and no one mentioned the fee-for-service system, which makes the whole thing unsustainable.

Broadband and health

David Glance: It was clear that both ministers are not experts in this area. Telehealth is always equated to videoconferencing and Plibersek ignores that this is already largely in place today, even without the NBN. Telehealth is much more – especially asynchronous Telehealth whereby images and assessments (among other things) are sent to a specialist for review and comment.

Telemonitoring does not require particularly high bandwidth or the NBN and adoption of both this and telehealth is still relatively low – not because of technology but because of lack of training, lack of health processes adapted to this mode of health care and lack of financial support and incentives.

Plibersek was incorrect to suggest that the opposition’s broadband solution would not support telehealth and Dutton was correct to say that satellite would still be the only thing provided to some remote communities in both models of the NBN.

Dementia prevention

Michael Valenzuela (who posed the question): The minister failed to catch the essence of my question, which was about a plan to prevent dementia. It is only through a co-ordinated national prevention plan that we can have any hope of averting or minimising the truly scary dementia numbers that await us. Rather, she listed a series of funding initiatives related to dementia care and treatment – precisely the kind of response I was hoping to avoid.

The shadow minister at least seemed to understand my question and talked about the dementia “tsunami” coming towards us, and that medical research is very important in that respect. Agreed – but no concrete plan, initiative or strategy.

More generally, I was left with a sense of deep disquiet that neither current minister nor alternative minister was able to articulate a clear and progressive vision for Australian’s health.

Rather, there were lists of issues, transactional arguments and self congratulation. Australia needs a clear vision for our future health.

Private health insurance rebate

Elizabeth Savage: The 30% rebate on private health insurance premiums was a very expensive and ineffective way to relieve pressure on public hospitals. Predictions from the industry that there would be a large reduction in coverage when the rebate was means-tested have proved to be incorrect – coverage has increased.

The age loading applied under the Lifetime Health Cover Policy did increase coverage. However, it did not fulfil the prediction of lower insurance premiums, as a consequence of the pool of insured people being younger and having lower claims. Premiums did not fall.

Removing the 30% rebate from the age loading applied under the Lifetime Health Cover Policy will reduce the cost to revenue of the misguided 30% rebate.

** Reema Rattan is Health & Medicine Editor at The Conversation 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

In the article below, she reviews Primary Care and General Practice in Australia 1990-2012: A Chronology of Federal Government Strategies, Policies, Programs and Funding,  by Dr Lesley Russell from the Australian Primary Health Care Research Institute.

Despite the extensive changes that have occurred in the primary care sector over the past 20 years, it is questionable whether we are any closer to a system that delivers consumer-focussed, integrated care, Doggett says.

She suggests it may be time to admit the limitations of our fee-for-service system and look for an alternative funding model for primary care. We also need to develop better ways of measuring performance in the primary care sector.

 ***

What can we learn from 20 years of primary care reform?

Jennifer Doggett writes:

Much of the success of the current health reform agenda depends on what happens in the primary care space.  If the reform measures deliver a stronger primary care sector – specifically in terms of accessibility, preventive health focus and chronic disease management – many of the goals of the reform agenda will be achieved.

Conversely, if the primary care reforms don’t improve on current performance in these key areas, our health system will continue to cost more and deliver less.

Achieving success in reforming the primary care sector requires both a comprehensive plan and its successful implementation. Learning from previous attempts to introduce major changes into primary care and general practice sector can help avoid past mistakes and increase the chance of success.

However, learning from experience is not a strength of the Australian health system. We have eight States/Territories which often do not share their knowledge and experience within each other and frequent changes of government and a fluid bureaucracy means that there is often little ‘corporate’ memory of past changes among those with the most policy influence.

For this reason it is vital that policy makers and managers working to implement the current primary care agenda have access to resources like the one recently published by Dr Lesley Russell from the Australian Primary Health Care Research Institute.

This paper Primary Care and General Practice in Australia 1990-2012: A Chronology of Federal Government Strategies, Policies, Programs and Funding  provides a detailed overview, from both a policy and budget perspective, of the way in which primary care has been delivered in Australia over last two decades.

The paper covers the period from the introduction of the General Practice Reform Strategy in 1992 to the introduction and early days of Medicare Locals in 2012. It covers 19 Federal Budgets, eight Ministers for Health (under four Prime Ministers) over a period almost equally split between Coalition and Labor Governments.

Among the programs and initiatives covered in this comprehensive paper are: Divisions of General Practice; the Practice Incentives Program; the Primary Health Care Research Evaluation and Development Strategy; the General Practice Immunisation Incentives Scheme; Enhanced Primary Care; Primary Care Collaboratives; SuperClinics; Chronic Disease Management item numbers; and Medicare Locals.

It seems incredible that this is the first time this information has been gathered together systematically in one place, given that the primary care sector is so crucial to the overall performance of our health system.

While there have been numerous reviews, evaluations and reports on aspects of primary care produced over this period, the lack of institutional memory means that often these lie buried on website or within Departmental archives and are not used to inform current policy development processes.  This means that all too often Ministers and their Departments fail to benefit from the lessons of recent history when attempting reforms in this area.

One key issue that this paper reveals is how much change has occurred in this sector over the past 20 years. A doctor starting to practise in 1992 would have spent his/her entire professional life dealing with major policy changes, new initiatives, changes to funding arrangements and all their associated administration and jargon.

Given this high degree of change, it is understandable that many GPs appear cynical and jaded when faced with yet another reform measure.

The problems of fee-for-service
Another issue this paper makes apparent is the high number of initiatives introduced over the past 20 years that attempt to address the problems caused by our fee-for-service based Medicare system. This payment system works for one-off episodic care but is not well designed to promote preventive care or chronic disease management which requires ongoing care across different health sectors.

Many, if not most, of the reforms over the past 20 years in primary care are attempts to use Medicare to shift from its original focus on episodic care to a funding system which promotes quality and rewards outcomes rather than process. These include the General Practice Immunisation Incentives Scheme, Enhanced Primary Care and the Chronic Disease Medicare item numbers.

After 20 years of this approach, we may have got better at targeting the payments and tweaking the incentives of targeted programs such as these.

However, it is questionable whether we are any closer to a primary care system that delivers consumer-focussed, integrated care. We still cannot deal well with prevention or chronic disease and have a hospital system faced with increasing numbers of avoidable admissions every year.

Perhaps it’s time to admit the limitations of our fee-for-service system and look for an alternative funding model for primary care?

Unanswered questions about performance
Another point highlighted by this paper is how little idea we have of how to measure performance in the primary care sector.

Despite the millions of dollars poured into general practice and primary care initiatives over the past 20 years, there has been no systematic attempt to measure their impact in terms of the health status of the community.

While some individual initiatives have been evaluated, that was mostly done in terms of process (e.g. numbers of services provided) rather than looking at their cost-effectiveness in achieving a positive impact on the health and well-being of the community.

As a result we have failed to develop a sound understanding of the most effective ways of driving change within primary care, an understanding which would greatly assist in implementing the current health reform agenda. To ensure this does not occur again, we need to ensure we develop an agreed set of goals for the current reform measures and evaluate their impact in relation to these goals post-implementation.

For anyone who has been around general practice or primary care at some level over the past 20 years, this paper will prove informative and interesting.

For anyone who plans to be around this sector for the next 20 years, it will be an essential resource.

Disclaimer: Jennifer Doggett has previously provided consultancy services to the Australian Primary Health Care Research Institute

Link: http://aphcri.anu.edu.au/sites/aphcri.jagws03.anu.edu.au/files/panel/416/primary_care_and_general_practice_final_v3.pdf

While independent, government-funded Medicare Locals are still in their embryonic form, opposition health spokesperson Peter Dutton has hinted that, if elected, a Coalition government would scrap the bureaucracies and redirect funds to front-line patient care.

“We support a role for the coordination of primary care, but we don’t support money being prioritised away from patients into vast bureaucratic structures,” Dutton said last month, though the Coalition has not clarified its position on Medicare Locals.

Medicare Locals coordinate (but only provide a limited range of) health services. They’re designed to identify local needs, streamline patients’ journeys through services, support health workers, facilitate initiatives and be accountable to the community.

There are already encouraging signs that Medicare Locals are starting to deliver results. But if they’re axed, Australia could be derailing its path to a more equitable health system.

Early signs of progress

For the first time, primary health-care providers across Australia have come together to plan after-hours services to meet the needs of their local communities. In the Hunter, New South Wales, for example, a telephone triage system helps patients access services they need, including transport. This takes the load off hospital emergency departments, which treat patients if they’re unable to access a general practitioner after hours.

Many other Medicare Locals have established websites where patients can find an after-hours GP in their local area. These services are linked to the national after-hours GP help line which is particularly useful in providing advice for parents when their young children get coughs or fevers.

Other Medicare Locals are working on increasing access to doctors and allied heath-care providers in nursing homes, again preventing unnecessary trips to emergency departments.

Addressing inequality

Certain groups of Australians suffer disproportionately from health problems. Indigenous Australians, people from lower socioeconomic backgrounds and those living in rural and remote areas are at higher risk of chronic diseases such as diabetes and heart disease.

The life expectancy gap between the most and least disadvantaged parts of NSW, for example, is 4.6 years. And Indigenous Australians’ life expectancy is 9.7 and 11.5 years less for women and men respectively.

This is partly because disadvantaged groups have higher rates of risk factors such as obesity and smoking but also unequal access to preventive and other health services.

In some areas, many people were born overseas, have poor English language skills, limited education or poor health literacy (the knowledge and skills to stay healthy). This complicates preventive care and early treatment.

In an attempt to address this problem, Sydney’s Inner West Medicare Local has been funded by the National Preventive Health Agency to work with GPs, local government and community organisations to engage people with poor health literacy in preventive care.

A quality primary care system

Australia has a comparatively strong but fragmented primary health care system. An older person needing extra help at home, for example, often has to be assessed by a number of service providers separately and often information is not shared. This frustrates patients and their families as they receive uncoordinated or inappropriate services. Fragmented care is particularly detrimental for older people and those with complex long-term problems such as diabetes and depression.

International research has demonstrated that primary health care is a key part of the solution to these inequities. This is because disadvantaged and vulnerable groups are more likely to have multiple risk factors and health problems – and primary health represents a comprehensive means of diagnosis and management. It is also generally more accessible and affordable for people with limited resources than more specialised care.

Good care requires strong links between hospitals and community-based services, multidisciplinary team care and proactive approaches to prevention, something many hope the Medicare Locals will achieve.

A major opportunity comes with the Health Communities plans Medicare Locals are currently developing for their local areas. These will identify which population groups are using services and then develop more flexible locally responsive services. So far, some Medicare Locals have found children in disadvantaged suburbs have lower rates of immunisation and thus they can work with the other local health services to improve access and promote uptake in these areas.

Where to next?

The Commonwealth government has invested approximately A$171 million a year to fund the 61 Medicare Locals across Australia. This is a relatively small amount of money in the A$53 billion-plus health and ageing budget.

The health care reform reports recognise the pivotal position of primary health care in preventing more acute illness and saving money down the track, with Medicare Locals playing an important role in prevention and early detection.

Although there is goodwill for Commonwealth- and state-funded services to work together at the local level, more integrated care involves making health professional roles and services more flexible. These changes are difficult to achieve across different professions, organisations and with limited resources.

The success of Medical Locals at reducing health inequities will depend on their ability to relate to local communities. If Medicare Locals can work with local government and those representing vulnerable and disadvantaged groups – and listen to what they have to say – they may be able to tackle problems that more established services have not.

These long-term relationships will need commitment and trust. They also require time – something that Medicare Locals may not have.

** Mark Harris is Director of the Centre for Primary Health Care and Equity and the Centre of Research Excellence in Obesity Management and Prevention in Primary Health Care at the University of NSW. He is also a board member of the Inner Western Sydney Medicare Local; Elizabeth Harris is a Senior Research Fellow at the University of NSW; Nicholas Zwar is Professor of General Practice and Head of Undergraduate Education at the University of NSW’s School of Public Health and Community Medicine. He is also a board member of the South East Sydney Medicare Local.

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence. 

It is well established that many people from lower socioeconomic groups have inadequate access to healthcare. In the Canadian province of Ontario, Michelle Olah and colleagues from the Centre for Research on Inner City Health investigated the influence of perceived socioeconomic status on access to primary medical care. In this well designed study, one female researcher and a male counterpart were randomly assigned to telephone the offices of 375 randomly selected Toronto family physicians and general practitioners, seeking appointments as new patients. Also randomised were high versus low socioeconomic status (revealed verbally by referring to ‘my welfare worker’ and in responses to routine questions) and presence or absence of chronic health conditions (diabetes and back pain).

In Ontario, all residents have health insurance coverage provided by a single public insurer, with no patient co-payments, so doctors are reimbursed the same regardless of patients’ socioeconomic status. Consequently, this study was able to investigate the influence of perceived socioeconomic status separately from differential reimbursement incentives.

The results confirmed the authors’ expectations: prospective patients portrayed as higher socioeconomic status were significantly more likely to receive an unconditional offer of an appointment. Chronic health conditions also significantly increased the likelihood of appointments, independently of socioeconomic status.

The most common justification for not offering an appointment was that the doctor was not accepting new patients. According to Statistics Canada (2011), 15% of Canadians did not have a regular doctor in 2010, and the main reason reported by those who had tried unsuccessfully to find one was that local doctors were not accepting new patients. This suggests that discrimination on the basis of socioeconomic status may be a major contributor to the problem. However, Olah and her colleagues acknowledged that their study was unable to distinguish between socioeconomic discrimination and welfare-status discrimination.

Access to healthcare is of course only one channel through which disadvantage and discrimination can impact on health; many of the effects of social determinants of health act more directly on health, for example through food insecurity and inadequate housing. However, lack of access to primary medical care is a significant barrier to good health.

Surprisingly, the authors did not mention the inverse care law. The findings support the main claim of Julian Tudor Hart’s theory, that ‘availability of good medical care tends to vary inversely with the need for the population served’ (p. 1), but not his contention that this pattern of inequality is driven by profit.

In the articles below, Marge Overs reports on the role of physician assistants in improving Aboriginal healthcare, and Kay Coppa, community and public health director at Miwatj Corporation Aboriginal Health in Nhulunbuy, reports on two presentations that she found particularly noteworthy.

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A day in the life of a physician assistant in an Aboriginal health service

Marge Overs writes:

If you’ve ever wondered what a physician assistant (PA) does in a rural practice, Nanette Laufik set the scene in her presentation to the 12th National Rural Health Conference, where she described her work in an Aboriginal community-controlled health service.

Nanette, a US-trained PA, works with Dr David Baker at the Mulungu Aboriginal Corporation Medical Centre in Mareeba in far north Queensland.

She said David had found it difficult to recruit GPs and decided a PA could benefit the centre in several ways: to help with chronic disease management planning and follow-up; to make the clinic more economically efficient (through Medicare billing); and to make more efficient of his time, so he could devote more time to more complex patients and to teaching students and junior doctors.

On a typical day, Nanette says she sees an average of about eight patients under various chronic disease management programs (see table below).

Each patient spends about 40-60 minutes at the clinic: the first 10-20 minutes with the Aboriginal health worker who orders tests and checks for any pressing problems; the next 20-30 minutes with Nanette, who reviews test findings and medications, and talks about lab results and specialist appointments.

For the final part of the consultation, Nanette briefs Dave on her findings and together they formulate a treatment plan.

All the while, the emphasis is on patient-centred planning.

“It’s the patient’s care plan – it’s what is important for the patient in terms of their goals, not my goals,” Nanette says. “My goal might be to get their diabetes under control – they may want to lose weight so they can play with their grandchildren. Patients come up with ideas that are more meaningful to them than me saying they needed to get the HBA1c down.”

And it’s working: she says patients are missing fewer GP and specialist visits, and the practice is also benefiting economically, with Nanette generating almost four times her income in Medicare billings.

“My annual salary for two days a week is $40,00 and I generated $156,000 in Medicare billings,” she says. “Dave is also using his time more efficiently: he’s able to spend more time with teaching students and junior doctors and his quality of life has increased too, as he’s been able to get away on time to coach his young son’s cricket team.”

She says the PA is a true workforce multiplier, “readily fitting into the rural health scheme, working closely with the senior medical officer and improving the efficiency, productivity and financial returns of this chronic disease clinic”.

But as previous Croakey posts have covered (see below), barriers remain to the wider use of the PA role:

• Health Workforce Australia report highlights the demand for PAs
• Physician assistants win support of rural and remote doctors
• Professor Peter Brooks on why Australia needs PAs 

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Disparities in ischaemic heart disease care for rural Aboriginal people

Kay Coppa writes:

Derrick Lopez, from the University of WA, presented a study on disparities in ischaemic heart disease care for rural Aboriginal people.

Although Aboriginal people are three times more likely to have an ischaemic heart disease event compared with other Australians, the study found they have lower rates of coronary artery procedures.

WA Hospital morbidity data showed that compared with non-Aboriginal people, Aboriginal people were younger, more came from remote areas, fewer were transferred to metropolitan hospitals by the second day and fewer received an angiogram. Significantly, many fewer Aboriginal people had private health insurance.

The audience wondered why care was so different for Aboriginal people: whether this was just a problem in certain hospitals or it was a widespread problem. Unfortunately you couldn’t tell because the hospital’s privacy was protected.

Audience questions included:

• Were Aboriginal liaison people employed at the hospitals to assist Aboriginal people understand what was happening and make decisions about important tests and where the relevant care was provided?
• Was there equal access to investigations and treatment based on need?
• Did private health status have any influence?
• Was there discrimination?

It seems a lot of people were very interested in this session. Conveniently, a workshop will be held next month in Adelaide at the Heart Foundation conference on this issue.

• More information on the research is here.

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A positive policing initiative helps people return to country

Kay Coppa writes:

Bernadette Rogerson, from James Cook University, spoke about a fabulous Cairns police initiative to help the high numbers of homeless Aboriginal people get back to their remote communities. This is also problem in Darwin and I wonder where else.

Many of these ‘homeless’ have been brought into the city for medical appointments or may have completed their term in a correction facility but can’t get home.

It’s hard being disconnected from family, friends and country and being exposed to alcohol and other temptations, possibly missing flights and feeling bad about that.

Interviews that James Cook University researchers conducted with Aboriginal people after they got back to their remote communities clearly showed their appreciation, particularly for one specific police officer.

How much better for everyone. Cities don’t have the ‘problem’ of homeless people, and Aboriginal people don’t feel lost and lonely, don’t end up drinking too much and maybe getting into other strife and aren’t wandering around for weeks sometimes trying to find somewhere to stay, look after themselves and get home.

Ah, but the funding runs out soon ….

• Kay Coppa is community and public health director at Miwatj Corporation Aboriginal Health in Nhulunbuy.

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Previous Croakey articles on the 12th NRHC

• An uplifting start 

• What does it take to address the social and economic determinants of health in rural and remote Australia?

• What are the critical health issues for rural and remote communities?

• Introducing a new Croakey service, launching at the national rural health conference

Details and declarations re the Croakey Conference Reporting Service are outlined here.

As future funding arrangements are developed, it is important that decision making is informed by reliable data and contextual understanding, says Selwyn Button, CEO of the Queensland Aboriginal and Islander Health Council.

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For true primary healthcare and better outcomes, support community controlled healthcare

Selwyn Button writes:

Over the past few weeks, authorities have released a number of reports about the performance and expenditure of our national health system, and some of these relate directly to efforts aimed at improving the health of Aboriginal and Torres Strait Islander people.

This might seem a good thing on face value, as we need to know whether our efforts are making any difference, and where to direct resources in future to ensure ongoing outcomes.

But if this information is used without the appropriate context, it may be used as a means of reducing expenditure on Aboriginal and Torres Strait Islander health, in the name of creating ”efficiencies”.

This presents a significant risk for Aboriginal and Torres Strait Islander communities, as we continue efforts in improving the health of our people, while remaining at the whim of Ministers and government officials who rely on this information to determine policy priorities and resource investments.

What is needed now is for governments to re-think how we analyse, interpret and use data to inform ongoing priorities, practice and future innovation.

Firstly, let’s take the National Aboriginal and Torres Strait Islander Health Performance Framework report released in early 2013. and used as the main body of evidence for the Prime Minister’s Close the Gap Report card.  

This report clearly demonstrated that the most significant gains in access to care and improvement of outcomes is and continues to be achieved through the national network of community controlled health services.

Upward of 75% of health improvements outlined in the report were directly attributed to the community controlled sector, and clearly justifies the increased investment into community controlled services as the most appropriate provider of healthcare for Indigenous people as they are making the best health gains.

Secondly, let’s consider the most recent Indigenous Expenditure report of 2012 produced by the Productivity Commission, that averages overall Medicare expenditure on Indigenous people as 60 cents in the dollar compared to the rest of the Australian population.

As many readers would be aware, Medicare was created as a safety net to ensure that all Australians get access to required care and benefits through quality primary health care services.

With community controlled services focused on providing comprehensive primary health care to our people, efforts in increasing access to an individual’s entitlements through Medicare can and will be best achieved by our organisations.

In spite of this data, we now have more recent releases stating the overall expenditure of the National health budget is 1.5 times greater for Indigenous people than the broader population.

Additionally, we have received further data stating that mortality rates for certain illnesses are only reducing by slight amounts and chronic diseases are still high placing burden upon the public health system.

Although much of this information is already 2 years old by the time it is released, it fails to identify why much of the burden is borne by secondary and tertiary public health systems, as access to comprehensive primary health care is still limited for our people nationally.

Consequently, when you don’t have access to quality primary health care, many of our people will present at secondary and tertiary facilities when their issues have escalated to a point where hospital is the last resort, requiring treatment for not only one health condition, but generally 2 or 3 issues.

Even though we have over 150 community controlled organisations across the country, our services do not exist in every corner of the nation, and fundamentally this would be impossible to achieve without enormous costs involved.

Alternatively, what we should be aiming to achieve is to have a strong community controlled presence providing quality care to our communities in all areas with populations greater than 900 residents focused on increasing access to comprehensive primary health care.

Why primary health care?  Current and historical research by credible researchers have proven that the most effective means of delivering care and improving outcomes for Indigenous people is through community controlled services.

Health economists such as Professor Theo Vos and colleagues identified this in their work in assessing cost effectiveness of primary prevention activities across all health providers.  This work clearly highlighted that compared with government-run, mainstream and private services, community controlled organisations achieve close to 50% better outcomes than other providers in delivering care to our own people.

Although this method was documented to be more expensive than other models, the focus on outcomes should not be lost, as the only variable included in his analysis that increased the overall expenditure against the model was transportation services for clients.

Due to the implementation of a comprehensive primary health care model, transport services are a core component and will always be included within the community controlled delivery of care, which does not diminish the model but does and will continue to achieve far greater outcomes.

Unfortunately, the notion of ‘If you build it he will come..’ only works for Kevin Costner in the movies, and does not work to improve health outcomes for our people.

With all this data now publicly available for all to review and analyse, we must hope that in determining future policy and funding priorities for Indigenous health care, consideration is given to understanding the context and reliablity of the information.

Importantly, there already exists some credible evidence that encapsulates comprehensive primary health care delivery into a set of core functions.  This research was conducted and undertaken as a partnership between all healthcare providers, and should be the central component of any current and future policy debate about improving the health of Indigenous people, as it is widely accepted within the community controlled sector as the gold-standard in health service delivery for our people.

This work is the Core Functions of Primary Health Care in the Northern Territory, and with minimal adjustments to ensure local contexts are considered can and is applicable across all parts of the country.  Utilising the Core Functions as a means to support improving outcomes goes a long way to encapsulate high quality service delivery standards with current data and information to ensure that we are all targeting the right priorities, through appropriate mechanisms.

This was not evident at start of the COAG investment to support overall Indigenous improvements, which saw over 65% of the entire $1.6B commitment channelled into mainstream and government-run service providers, as it was determined the most effective way to improve outcomes.  Data was used showing that 70% of our people access care through government-run and mainstream services.

New data and information available now rebuts this myth that community controlled services have struggled with over the last 4 years.

Information now available within the community controlled sector shows that over 40% of Indigenous Queenslanders access care regularly through community controlled services, yet we are not in every part of the state.

With the end of the current Indigenous Health National Partnership Agreement set for 30 June 2013, we need to ensure that all of the relevant information and context is considered as part of ongoing discussions, policy setting and resource allocations to improve the health of our people.

Consequently, we are confident that this evidence will lead to what we have been seeking for many years – an increased investment in those services known to make a difference to the health of our people.  That is community controlled organisations.

• Follow Selwyn Button on Twitter @qaihc