In an ideal world: The Government's Draft Strategy for Primary Health Care
Australian Medicine, 21 September 2009
The health system would benefit from a more systematic response from primary health care, together with more effective integration of other health sectors with primary health care, according to the long-awaited Draft National Primary Care Strategy. The Draft Strategy was drawn up by DoHA, with the help of 265 submissions and assisted by an External Reference Group of primary health care experts.
Health Minister Nicola Roxon says that the aim has been to set out a road map for future policy, rather than a detailed implementation plan. The changes proposed were complex and would need more discussion. Meanwhile, the document points out that primary health care services have historically been delivered in a relatively unplanned environment.
Ageing, the growing burden of chronic disease and changes to the way in which care is delivered, particularly across acute and primary health care sectors, had placed increasing pressures on the health system.
Traditional organisational and funding structures were focussed more towards treating episodes of ill-health than on prevention and continuing management of disease. As the burden of disease moved increasingly to chronic conditions, enormous pressure had been placed on the service system.
There were disparities in access and outcomes in different parts of Australia and between different population subgroups that were often associated with disadvantage, perhaps most significantly for Indigenous Australians. Some people did not have the health literacy skills needed to navigate the system and were often left unsupported in their patient journey, the document says.
Primary health care services did not always provide adequate and culturally appropriate support and transitions across settings are not well managed.
Service delivery was characterised by multiple and fragmented funding streams and service delivery arrangements could be inflexible and poorly coordinated, not only in primary health care but also in hospitals, aged care and specialist care.
The Draft Strategy document pointed to a lack of good information and performance measures to support primary health care professionals, consumers, funders and policy makers.
Technological change had added costs to parts of the health system and opened opportunities to treat patients in different care settings, it said, often without accompanying care and follow-up. Use of technologies including e-health was falling behind consumer expectations, other service industries and progress in other comparable health systems.
Workforce shortages existed in most primary health care professions and were exacerbated by maldistribution. Funding arrangements, rather than clinical need, could determine the services to which people gained access and the health professionals who were involved in their care.
Current education and training arrangements did not support the future needs of primary health care.
'In summary, primary health care in Australia tends to operate as a disparate set of services, rather than an integrated service system,' the document says. It was difficult for primary health care to respond effectively to changing pressures (eg, demographic change, changes in the burden of disease, emerging technologies, changing clinical practice) and to coordinate in and throughout the various elements of the broader health system to meet patients' needs.
The primary health care services to which people had access and the quality of care that resulted could depend on where they lived, their particular condition and the particular service providers involved, as much as their clinical needs and circumstances, the document said.
Many patients, particularly those with complex needs, could either be left to navigate a complex system on their own or - even when supported by their GPs, - could be affected by gaps in information flows and limited ability to influence care decisions in other services.
The Draft Strategy offered four priority areas for investment and reform.
1. Improving access and reducing inequity
Directions for change
Primary health care delivered through an integrated service system providing more uniform quality care across the country, actively addressing service gaps and the needs of specific population subgroups.
What this would mean for patients
For patients, it would mean access to wellintegrated primary health care services that were more available, matched to meet peoples’ needs and providing continuity of care including safe handovers between care providers. For people with specific needs or difficulties in receiving care, service delivery would be responsive to their needs and circumstances
What the future would look like
Access to core services supported by universal access to a Medicare rebate will be retained but will be supplemented by targeted local programs and collaborations throughout the service system.
Through this combination of core services and targeted programs, accompanied by new funding and governance structures, primary health care services will be better integrated, will take responsibility for individual and population needs and deal with current variability in access and outcomes, including for after-hours access, traditionally underserviced groups and for patients in transition throughout the service system.
Service delivery will respond to the needs of those finding it difficult to gain access to mainstream services or who have specific health care needs either because of their location, demographic characteristics or health status or the circumstances in which they need care. Mainstream services will also be more responsive to the needs of different groups.
Service delivery and funding arrangements will support flexible service delivery models, promote effective and cost-effective use of technology and drive innovation by supporting information flows and workforce education and training.
The changes needed to get there
Primary health care services/organisations would need to monitor and implement programs to tackle service gaps and inequities in local communities.
Funding would need to support programs designed in local communities to deal with areas of market failure and promote connections across sectors.
Design features would need to fit local needs. Examples could include outreach programs to under-serviced populations (eg, people in aged care facilities with physical and intellectual disabilities and in under-serviced regions), transition services supporting patients on discharge from hospital or who need to navigate the system, team-based interventions focussed on providing joinedup, flexible services for the homeless or people with mental health needs.
Arrangements would need to be made for better access to after-hours primary health care and - building on Closing The Gap initiatives - health improved for Indigenous people. New infrastructure would need to support patient access, team work and integrated care solutions and better use of technology and outreach services.
The primary health care workforce would need support in under-supplied areas. Regional organisations and service providers would have the information and tools to monitor access gaps in their areas of responsibility and to respond where improvements were needed.
Professional organisations would encourage improved cultural awareness in service delivery.
'Measurable' change
Measurable change would be closing the gap in health outcomes throughout the population, with special attention to vulnerable communities
2. Better management of chronic conditions
Directions for change
A new approach to improve continuity and coordination of care, particularly for those with chronic disease, including through a comprehensive national approach to chronic disease management, tailored and delivered locally.
What this would mean for patients
Wherever they lived, eligible people with chronic conditions would be able to enrol with a practice or provider who becomes responsible for managing their care, monitoring progress and supporting self management.
Services, tailored to local service systems and needs, could include comprehensive multi-disciplinary team care, 'as needed' care coordination, sharing of information in and among providers and self-management support, including through diagnostic support tools.
What the future would look like
A new comprehensive approach to chronic disease management will recognise that individual consultations with GPs or specialists could not alone provide the range of integrated services needed to achieve long-term management of individual patients.
The new approach will provide improved health care for patients with chronic disease through flexible, tailored management of individual health care needs, with clear responsibility by practice or provider for patients’ management and follow-up.
Arrangements will include voluntary enrolment with a health provider based on clinical need, evidence-based and standardised assessment processes that identify eligible patients at various points in the service system (eg, hospital, specialist, community health), access to best-practice chronic disease management, based on assessed clinical need, flexible responses tailored to patients’ mix and level of services, supported self-management using available electronic and communication tools and, where appropriate, personalised shared care plans linked to patients’ electronic health records.
The changes needed to get there
Over time, chronic disease funding would be re-aligned with individual and community need. New chronic disease management approaches would be collaborative and patient-focussed, with consistent identification and assessment of patients and delivery of joined-up interventions.
In consultation with professional groups, improvements would be made to assessment tools and protocols and available evidence incorporated to ensure effective targeting of services and cost-effective use of system resources to achieve long-term health gains.
Self-management would be supported, with the use of modern tools for patients with chronic conditions that enabled monitoring of health status and alerts where appropriate.
Effective multi-disciplinary teams would operate, with appropriate use of the specialist workforce and supported by training, funding, infrastructure and technology.
'Measurable' change
For patients with chronic disease, there would be fewer avoidable hospital admissions and other key evidence-based clinical indicators of quality chronic disease management
3. Increasing the focus on prevention
Directions for change
The existing framework strengthened for promotion, prevention and early intervention in primary health care, to encourage more systematic approaches, with regular recall and follow-up, coordinated and integrated with other preventive activities, including a focus on improving health literacy, within local communities.
What this would mean for patients
Individual patients would receive regular risk assessments appropriate for their age and conditions available at multiple points of the service system (not just GPs) and linked with other community-based supports and activities. There would be higher levels of health literacy, starting at schools and building throughout the community to ensure that people have the skills and knowledge to manage their own health and are supported in doing so.
People would be supported to recognise their responsibilities more clearly and take positive actions to maintain their own health and wellbeing.
What the future would look like
Primary health care services will provide a range of preventive services to their local communities. All health providers, where they can, will use evidence to promote healthy behaviour.
Service delivery will be supported by data and information systems, including recall and reminders, and risk assessment tools. These services will be coordinated among providers in local communities to eliminate duplication and overlap and make best use of available workforce and provider networks, including nurses, allied health and pharmacists.
Targeted prevention activity will be focussed on hard-to-reach people, who may not otherwise be able to gain access to services. Primary health care services will be integrated with broader prevention activities at the local level, to link patients with community-based supports and activities and receive feedback on patient progress from other services as appropriate.
The changes needed to get there
Health care organisations would focus on education and training on effective preventive activities, communication of broader preventive health initiatives, uptake of tools and information systems to support preventive care. Service delivery and funding arrangements would support best use of the available workforce, including nurses, allied health and pharmacists.
Supplementary prevention services would be supported by new arrangements for individuals and practitioners, focussed on high-risk populations and those conditions and behaviour where prevention and early intervention could result in significantly improved outcomes and system-wide effectiveness and cost-effectiveness. There would be focus on improving community and individual health knowledge and providing education and support to individuals to manage and improve their own health.
'Measurable' change
Lifestyle risk factors would be reduced for chronic disease such as smoking and obesity, especially for vulnerable populations.
4. Improving quality, safety, performance and accountability
Directions for change
A strong framework for quality and safety in primary health care, based on improved information and quality assurance systems to support measurement, feedback and quality improvement for providers and greater transparency for consumers and funders.
What this would mean for patients
They would have enough information about health providers, facilities and services to help them make informed choices about their care. Patient care would be based on the best available evidence. Safety and quality would not be compromised through poor information at patient handover or a lack of information on performance and quality of services in different parts of the system.
What the future would look like
Access to information on safety, quality and performance will drive continuous improvements in primary health care services and improved health outcomes for patients.
Service providers and regional primary health care organisations will have the tools to reflect on the effectiveness and cost-effectiveness of their services and to adapt to emerging challenges and population needs.
Primary health care professionals will work within a performance framework that meets their needs, supports peer feedback and comparison as part of continuous quality improvement and recognises the challenges of measuring performance throughout all the aspects of primary health care.
Providers of publicly subsidised primary health care services across the workforce will be accredited against comprehensive standards for primary health care services. Primary health care will be supported by research that is timely, accessible and applicable to policy and service delivery.
The changes needed to get there
Engagement with the community and with health providers about how the effectiveness of the primary health care service system should be measured and monitored over time with e-health records able to track care and treatment of individual patients.
Knowledge support systems and information should be developed to inform practitioners about their performance and give them the capacity to compare themselves with their peers or against best practice. Care delivery would ensure appropriate use of the workforce, matching roles and responsibilities with'scope of practice'. Agreed performance indicators would be implemented throughout primary health care settings to drive improvements in practice and to inform consumers and policy-makers.
'Measurable' change
There would be fewer avoidable errors attributed to safety and quality issues.
The full document - Building a 21st Century Primary Health Care System - can be found at www.yourhealth.gov.au
