There is some essential new reading for those concerned with primary care and related reforms, according to health policy analyst Jennifer Doggett.
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