Raising the Care Factor: Royal Commission into Aged Care
Dr Ayman Shenouda
There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care.
I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve.
This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents.
What have we learnt?
Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind.
The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years.
The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive.
It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009.
Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift:
"…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies".
Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here.
The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers.
Ensuring quality care
This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction.
Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector.
I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission.
One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model.
This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised.
Ensuring a key role of general practice in aged care service provision is integral to the solution.
The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time.
It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review.
What are the priorities?
A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness.
Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS.
Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement.
Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this.
More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity.
In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team.
These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences.
Training and roles
Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care.
In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios.
The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles.
Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets.
They must be properly paid and qualified for what is a role which carries with it a lot of responsibility.
Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents.
But RNs who work for nursing homes also tend to earn less than those working for other major employers.
In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure.
Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night.
This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care.
New models of nursing-home care
It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place.
There are also excellent models of care within Australia but we need a funding system to prioritise support of their development.
We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing.
These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
Federal Budget 2018
Dr Ayman Shenouda
Expectations around this year’s Federal Budget were high. The Government certainly worked hard in its lead up trying to lower expectations promising an economically responsible and fair budget.
We knew we would see an election budget here and with that, we expected a strong focus on some key areas important to the majority of Australians.
Voters wanted to see a focus on cost of living pressures and improving the health system and these two items came out on top in earlier polling.
A budget for a healthier Australia?
So, what is the verdict - is this a budget for a healthier Australia?
There were certainly strong gains in rural health, aged care, mental health and medical research.
There are some really positive initiatives in this budget but at a time of record inequality, more wellness measures through formalising a preventative health strategy would have made this a great budget.
This is required to help drive a strategy forward to really address some of those causes of ill health.
Spending measures in countering the high numbers of our population who are overweight or obese, for example, are needed and it would have been good to see some strategy around this.
We all know to get to the bottom of the causes of health disparities then the focus needs to be on those social determinants of health.
The investment is beyond health and an overall policy approach to protect those factors which stretch a range of personal, social, economic and environmental factors.
Primary prevention focus
A strong and broad primary prevention focus is needed to counter those health risks factors and improve health outcomes for all Australians.
This budget does pick up a number of these issues, including for women’s health and wellbeing and more broadly through its More Choices for a Longer Life Package.
Mental Health funding of $338 million and priority on suicide prevention clearly goes a long way towards addressing the system gap around crisis support.
The allocation for older Australians which includes $83 million for more services within the RACF, again addressing a significant gap, is a really positive step forward.
While short on detail, the new primary care funding model for the Indigenous Australians’ Health Program is another key area which required focus.
The increases for PBS and new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs all represent a significant health investment.
The standout here in terms of addressing disparities and ensuring a primary prevention focus is the rural investment and the Government has certainly delivered here.
Equity for rural Australians
The key rural health workforce measures are provided through the $83.3 million new Stronger Rural Health Strategy which includes some solid measures to secure more GPs for rural Australia.
This is a 10-year plan and a $550 million commitment which promises 3000 more doctors, 3000 nurses and hundreds of allied health professionals to our regions.
The plan provides an unprecedented level of funding and commitment for rural Australia and its packed with measures that show the Government has listened on addressing rural health need.
The workforce component will see integration through the entire training continuum as well as measures to support the existing rural workforce with an important focus on retention.
Stronger targeting of rural bulk billing incentives and key focus on accessing rural services particularly for older Australians with $40 million towards rural aged care infrastructure another positive shift.
For Aboriginal and Torres Strait Islander communities, there is a $105 million boost towards access to services which are culturally appropriate and closer to home.
There is a new MBS item to deliver dialysis services to remote areas representing a $35 million investment.
We have some great leadership here at the moment in our Rural Health Minister, Senator the Hon Bridget McKenzie and Commissioner Professor Paul Worley and it shows in the budget.
Rural pathway package
The rural workforce package is certainly comprehensive and a significant step forward in securing a stable rural workforce with a number of the key components to this strategy covered in earlier blogs.
There is a priority placed on establishing a homegrown rural medical workforce with an important emphasis on skills.
Many of the placement gaps that make it harder to remain in a rural area have been addressed.
More intern placements in general practice and an additional 100 vocational training places are committed. The latter committed from 2021 as part of the National Rural Generalist Pathway.
New training facilities to help rural students aspiring to become rural doctors study closer to home is also welcomed.
The $95.4 million new Murray-Darling Medical Schools Network will help universities work together to support medical teaching in our regions.
It’s also great to see that the new Workforce Incentive Program will extend to supporting general practices to employ more allied health workers.
Strong IMG focus
It’s great to see strong action to ensure we retain the rural workforce in this package of measures which extends to providing incentives for IMGs to progress towards Fellowship.
Those working in rural areas know the huge contribution IMGs make and it is great to see the shift here towards IMG retention. These doctors play a vital role in rural and remote communities and they deserve some support.
The rural strategy outlined in this budget invests in the next generation through domestic recruitment to rural areas but shows a commitment to the existing workforce through investment in skills and retention with an important focus on IMG retention.
In Aged Care, reduced waiting lists and incentives to stay in the home longer sees another important policy shift.
Measures which keep older patients in their homes longer is welcomed policy with this initiative providing $1.6 billion for 14,000 new places for home-care recipients.
This is a good start but not nearly enough with more than 100,000 people on the waiting list. However, the policy is certainly headed in the right direction towards an integrated care at home program.
Some of these measures will restore some of the cuts to the aged care sector of recent years. But it is unclear if they will provide for the targeted supports needed to deliver the complex care required which needs more focus on enabling more GP-led care.
A healthier future
There are some major challenges in funding and delivery of healthcare in securing a healthier future and for this budget, we’re seeing shifts in the right direction.
Health is so integral to our nation’s prosperity and the Government through its investment particularly in rural Australia shows that it understands the value of general practice and primary care.
This budget will certainly improve the lives of the seven million people living in rural and remote Australia.
The rural health measures will help to address disparities and important gains will be realised through this investment and this is a clear win for the sector.
The mental health and aged care gains are also significant and it is great to see those more vulnerable Australians being prioritised.
Let’s fix the health deficit through a more equitable distribution
Dr Ayman Shenouda
The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development.
This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion.
The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes.
In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities.
Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World.
To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results.
Rural health disparities
The converse is, of course, true and this is why we have such marked health disparities in rural areas.
There is an estimated health deficit of $2.1 billion in rural and remote Australia.
The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is.
It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services.
In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage.
We need to focus on the value of working across sectors to address those causal factors.
It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.
These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities.
Rural health investments
Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. 
I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building.
We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility.
The economics of poor health
We know all too well the economic effects of poor health.
An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population.
But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well.
Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning.
Fixing the health deficit
We need to fix the health deficit through a more equitable distribution.
In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants.
It’s not just medical care alone that influences health with social factors known powerful determinants of health. This is the formula for a healthy Australia.
 NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf
 Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
 Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf
 Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/
Nowhere to go: tackling homelessness for older women
Dr Ayman Shenouda
A measure of our society
It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’. I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off.
On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care.
Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding.
Rising rates of homeless older women
One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports.
Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty.
Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes.
Combating ageism in our society is something this country really needs to work on.
How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future.
Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii] Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development.
My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time.
The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting.
We’ve been treating the symptoms and not the know causes for too long.
Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too.
It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii]
[i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/
[iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065
Australia needs to place a levy on sugary drinks now
Dr Ayman Shenouda
A sugar fix anyone?
Sugar certainly got some attention this week prompted by some important, corresponding, new research undertaken here in Australia[i] and in France[ii].
The first focussed on risks associated with fizzy drinks, while the other a little broader and on ultra-processed foods, but both found similar findings in terms of increased cancer risk. In a third article featured this week, in Meds Obs opinion, Dr Jon Fogarty wrote that we cannot allow another 50-year con job. I couldn’t agree more.
Rapid increasing consumption of lower nutritional quality foods is clearly driving an increased disease burden. It is those ultra-processed foods that we need to look at which contain high salt, trans fats and saturated fats along with sugar.
It was quite telling that the recent PC Report Shifting the Dial: 5-year Productivity Review, released in August last year fell short of recommending a sugar tax. This is despite a strong obesity emphasis in the report only called for a soft market control solution through voluntary reductions in sugar content (by major manufacturers of SSBs).
Many are comparing the current policy complacency in response to sugar, in particular, with the dangerously slow response to tobacco. And, I truly believe that if we were serious around prevention then we would be looking to a sugar tax here in Australia. If we are to shift health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. I’ve said that before but it needs restating particularly on this issue.
Consumers clearly need more help to identify those foods with added sugar.
Some of this work has been done through the Federal Government’s Health Stars Rating scheme designed to help consumers make more informed choices. But manipulative marketing seems to be out-tricking the system by making unhealthy products look healthy.
Choice put forward some good recommendations in August to make this system better. Making sure foods high in sugar, fat or salt can’t get a high star rating being their number one!
A Navigation Paper of the 5-year review of the Health Star Rating System was released in January. It will be interesting to see what changes are made in response to the review.
Placing a fiscal incentive through increasing the price of these foods would make for an effective solution. But, I really think a sugar tax is warranted here. And, if not a full sugar tax, then perhaps a health levy on sugary drinks is a good start.
The UK is leading the way with its plans to introduce a levy on sugar-sweetened beverages this year. Importantly, revenue will fund a prevention focus through expanded programs to reduce obesity and encourage physical activity and balanced diets for school children.[iii] Ireland is following with a levy coming into effect in April.
Closer to home, there seems very little appetite to introduce a similar levy in Australia despite calls from various leading health experts and many of the peak bodies.
Despite twenty-six countries placing a health levy on sugary drinks, we are not seeing similar leadership from our Government. Federal minister for agriculture and water resources, David Littleproud, said in January that governments “should not dictate the diet of citizens”, much to the delight of those industries that benefit from inaction.[iv]
Minister Littleproud heads a portfolio responsible for the investment in the development of Australia’s sugarcane industry. In my view, this is an issue that falls in the food safety category as excess refined sugar has undesirable health consequences. Therefore, despite where the legislation may sit, this is more an issue for the health minister.
There’s plenty of evidence
In terms of a need to take immediate action, we’re certainly not short on evidence here. And there’s now increased evidence to act on sugary soft drinks.
The French research I mentioned earlier looked at the risk between ultra-processed food and cancer. In this prospective study published in the BMJ, found a 10 per cent increase in the proportion of ultra-processed foods in the diet was associated with a significant increase of greater than 10 per cent in the risk of overall and breast cancer. ii
Proving that soft drinks elevated risk of cancer, the new research from the University of Melbourne and the Cancer Council Victoria released this week also found people who regularly drink sugary soft drinks were more at risk of cancer. i
Interestingly, this Victorian study showed that higher consumption of both sugar-sweetened and artificially sweetened soft drinks is associated with higher waist circumference. However, cancer risk was only higher among those who drink more sugar-sweetened soft drinks. This is an important finding as many opt for the alternative diet option or sugar substitute thinking it better, yet it also may be contributing to our obesity epidemic. i
Even more surprising, the key finding from this study that increased cancer risk is not driven completely by obesity. Those who are not overweight have an increased cancer risk if they regularly drink sugary soft drinks. i
We need action now
It is always those who can least afford it that suffer the most. Poor diet is more a result of poverty than a lack of understanding around the risks. The only food the poor can afford is making them unhealthy.
The key findings from these recent studies both in terms of ultra-processed foods and sugary soft drinks now link to increased cancer risk. This issue is a health priority and needs to be a key focus for the health ministry.
Let’s not sugar coat it – sugar and sugar sweetened drinks kill - we need action on this now.
[i] Hannink, N. Increased cancer risk from fizzy drinks – no matter what size you are. University of Melbourne. 22 February 2018. Available at: https://pursuit.unimelb.edu.au/articles/increased-cancer-risk-from-fizzy-drinks-no-matter-what-size-you-are
[ii] Fiolet, T., Srour, B., Sellem, L., Kesse-Guyot, E., Allès, B., Méjean, C., et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322. Available at: http://www.bmj.com/content/360/bmj.k322
[iii] Gov. UK. Department of Health and Social Care. Guidance: Childhood obesity. A plan for action. 20 January 2017. Available at: https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
[iv] Davey, M. Article. Health experts support sugar tax as coalition calls for personal responsibility. The Guardian. 8 January 2018. Available at:https://www.theguardian.com/australia-news/2018/jan/08/health-experts-support-sugar-tax-as-coalition-calls-for-personal-responsibility
A significant step in securing a stable rural medical workforce
Dr Ayman Shenouda
A rural renaissance
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice. These programs really work as they provide trainees with that essential insight to community medicine.
Intern rotations in general practice
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
Quality training experience
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
Keeping them there
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
A little on the policy journey
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
A win for general practice
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution.
Dr Ayman Shenouda
Shaping Australia: one GP at a time
For those who attended GP17 in October, I’m sure you will agree that it was delivered to its usual high standard and there was plenty of diversity in terms of viewpoints. Some perspectives were what could only be described as poles apart. Dr Jay Parkinson and Sir Harry Burns for example.
Dr Parkinson with his discussion around consulting in the cloud through to Sir Harry’s on tackling poverty. There have been some blogs and articles around the technology discussion including recent Opinion in the Medical Observer.
It was Sir Harry’s discussion that moved me the most as he provided some important insights into poverty and particularly around social chaos and its flow-on effects in eroding wellness. In some ways, this discussion gave me renewed hope. That as a community we can together tackle disadvantage particularly in ensuring our children get the best start in life.
Not enough wellness
Sir Harry Burns from Strathclyde University and former Chief Medical Officer for Scotland provided the research keynote address. This was a spirited defence of poverty which really got to the heart of the issue.
The issue, of course, being disparities in terms of health outcomes and ways to counter these. It’s about how societies can create wellness and also how they can destroy it. In explaining this, he brings the consequences of poverty and inequity into sharp focus.
His own country’s poor health, he says, is a reflection only of the health of the poor. Studies he’d undertaken led him to believe that the problem was in fact not enough wellness (and not too much illness). Social conditions as fundamental causes of health could be seen through countless studies he shared.
We’ve all seen this of course in our own communities. I know in Wagga like most regional towns there are some deeply entrenched social disparities. But in addressing these, our national policy I think is structured in a way to deal with consequences, not poverty prevention and reduction. And without significant change, these patterns will only continue.
The science behind wellness
Sir Harry’s work has sought to unravel the science behind wellness. And I think some of the key learnings from his research can really transform our policies here in Australia today.
It was the work of a colleague, Professor Alastair Leyland, which examined his own community of Glasgow against the slope index of inequality, which began his own inquiry around what causes health inequalities.
Some very specific insights were shown in terms of what happened in society to slow down growth and life expectancy in the poor. The peak in mortality shown in these studies was in the young – teenage and young working age people – and from very specific causes – drugs, alcohol, suicide, and violence.
Inequality mortality was not a feature of the elderly. These were not people dying from heart disease or cancer but there was something else going on in the population. These outcomes were pyschosoically determined - society determined causes of premature death - and they needed to work out what the key drivers were.
It was social chaos that intervened which came with the housing disruption more than five decades ago. Traditional communities were broken as a consequence alongside loss of employment, opportunity, and hope. This was what eroded wellness and it is clear the same social disruption occurred here and we are also dealing with these same issues.
Causes of wellness
Looking more to those causes of wellness. Salutogenesis and the work of an American Sociology Dr Anton Antonovsky around a Sense of Coherence which relies on a life which is structured, predictable, explainable. Having resilience or the internal resources and will to deal with challenges.
In quoting Antonovsky he said: “Unless you can see the world as comprehensible, manageable and meaningful you will experience a state of chronic stress.” This provided what he was looking for. It showed the link between social circumstances and ill health.
Poverty and elevated stress
The research presented really showed the relationship between poverty and elevated stress and how that leads to chronic disease and ill health. Those with a difficult start are less equipped to adapt to change which often manifests in poor behaviours.
Studies by Bruce McEwen of Rockefeller University has made those links as well as Sir Harry’s own associated work undertaken in Glasgow. Early-life stress and the long-lasting behavioural, mental and physical consequences. For those wanting to learn the full science behind this here is his presentation and this discussion is about 20 minutes in.
And there’s something in a cuddle.
The molecular biology of a cuddle was shown. Comforting and its effect on suppressing the stress response. The biochemical toll of early neglect. Stress in infancy and the fact that neglected babies don’t get enough 5-HT.
The work of Michael Meaney’s and the difference in brain development for those children who experience adversity in early life was shown. Other studies were shown which have looked at different types of adverse childhood events – neglect, abuse, domestic violence, alcoholic parent – which is then linked to outcome. It showed children exposed to adverse events in early life had a higher risk of alcoholism, depression or drug abuse.
Breaking the cycle
Social turbulence was the description used. More specifically, he described a cycle that alienates people and impairs their ability to control their wellbeing. And that it starts with chaotic early years.
The policy learnings for us include around Scotland’s approach to improving wellness. That is to focus on breaking that cycle by doing things in early life.
There are some key learnings in the policy approach itself. It was those at the front-line who developed the policy solutions in Scotland in response to these issues. They asked front-line staff for solutions, then took their ideas and tested them and shared them across the country.
The secret, he says, is in marginal gains. Go out there try lots of things see what works and then do it all consistency. I think there’s a lesson in that for our own policy development.
It is through those small gains which from a range of interventions that add up to produce significant overall improvements. In early years, it was simple things like attachment is improved if kids are read bedtime stories. The solution lies in enabling that to occur.
The shift in policy approach is really about enabling policy change. That is change as opposed to full reform. It is in enabling those incremental shifts to existing structures, or the adoption of new and innovative approaches that can facilitate that change.
The risk in full reform is that it stifles innovation which can limit participation and if it’s not realised quickly then all is lost including those approaches that proved to work. Politicians turn to the next new thing which may not be as effective.
In Scotland, they’ve had 1500 small tests of change carried out in child health with 60 or 70 of them now implemented. Similar community strengthening type approaches which can facilitate incremental gains are what we need here to shift disparities.
The key message from the discussion is that it is those experiences in early life which can set off a life course of adversity. Those clear links in social circumstances and the beginnings of chronic ill health.
We need much more focus here in Australia on what causes wellness. It’s not that we haven’t had a focus here on concepts which include community resilience. Those social capital discussions were full of it in the early 2000s.
There seems less focus now and perhaps its due to governments not realising fully how investments now pay health dividends later on. There also may not be that political will to invest in wellness knowing the results will not be seen in the space of an electoral term.
24 November 2017
Dr Ayman Shenouda
National Aged Care Quality Regulatory Processes Review
The recent Review of National Aged Care Quality Regulatory Processes was released on 25 October. The review looked at past failures in terms of the limitations of the regulatory controls to recognise abuse and care issues. It’s emphasis, therefore, was on improved regulatory measures to improve national monitoring arrangements.
Aged Care Minister Ken Wyatt, in his announcement on releasing the report, stated that the majority of facilities provide excellent care and are working to continually improve services. Some might argue that media reports of endemic abuse in nursing homes paint a very different picture. That aside, the Minister stated that focus was on seeing improvements to the system that can address those not delivering quality care.
Aged care safety and quality
It is appropriate for the review to have a core focus on safety and quality. The capacity of the current regulatory environment to protect residents from ‘restrictive practices’ is of course appropriate. A key recommendation was the use of unannounced audits across Australia’s residential aged care facilities (RACF). This is a positive outcome and the commitment by the government to implement this recommendation quickly is also positive news.
There were 10 recommendations in total to improve aged care resident protections through more transparent compliance and monitoring. Other key recommendations included establishing an independent Aged Care Quality Commission with provision for a quality commissioner, complaints commissioner, consumer commissioner as well as a chief clinical advisor. This new commission would develop and maintain a centralised database with the view of creating a star-rated system on provider performance.
In addition, there would be more protections to curb abuse which would see a recommendation from the Australian Law Reform Commission for a new independent serious incident response scheme (SIRS). On accreditation and compliance, the unannounced visits were the major recommendation with more public disclosure on matters of non-compliance. In addition, if supported, there would be strengthened controls around medication reviews and compliance. Medication reviews were recommended on admission, after hospitalisation, upon deterioration or when changing medication regimes.
Where’s the focus on general practice?
This is an important body of work but again we see a lack of insight into the key role of general practice in aged care service provision. This is another example of a review which has missed an opportunity to ensure a stronger role for GPs. There should have been scope to work through key issues including those areas of clinical governance as a key quality enhancement measure.
It’s all very well to make sure that there are controls to pick up those not doing the right thing. But doesn’t it make better policy sense to place an equal emphasis on why the issues are there in the first place?
It is very disappointing that this review did not extend to service solutions through general practice.
This oversight being on the back of the recent Productivity Commission’s 5-year productivity review – Shifting the Dial - which also underplayed the role of general practice in a discussion which focussed on prevention and primary care.
To a certain extent, even the changes in Victoria with the voluntary assisted dying legislation seem to lack a focus on service capability. Palliative care is one area which lacks clarity in terms of roles and most certainly there is a lack of data, fed by physician only item numbers, which can only constrain services and planning. GPs too do a lot in this area but this mostly goes unnoticed and underfunded. Ensuring there are funding levels to enabling access to palliative care services should be a priority moving forward.
Valuing general practice
Why is there a lack of focus on general practice? It’s clear that success in terms of prevention makes us far less visible. Such is our role that if we do it well then it goes unnoticed. Best practice interventions for heart disease and stroke, for example, will translate over time through improvements in data. But there’s a very limited audience with not many from outside of the profession interested in this level of detail.
The RACGP has made strong investments in recent years to lift our profile. However, the lack of focus is still a key problem. This is evident in this latest report where glaring service solutions – solutions to lift quality - have been again overlooked.
The missing GP perspective
In a recent Medical Observer article by Professor Leanne Rowe, ‘Why are GPs missing for the national aged care review?’, this lack of focus was also seen as a key issue which limited the report’s findings. The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities.
Those obvious service issues, central to ensuring quality, were ignored. A focus on quality needs to also look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
The role of the GP is clearly limited due to low rates of reimbursement through the MBS. Optimal models of care cannot work in an underfunded service environment.
GP-led care or collaborative care solutions are relevant to achieving those safeguards for residents sought through this review. Stronger integration of GPs and improved collaboration with aged care staff and formalising these models of care would assure safe and high quality coordinated care for residents.
More broadly, variable skillsets are important factors that impact on quality of care standards in these facilities. Inadequate staffing levels including the need for more skilled nursing staff is central to many of the quality and compliance issues central to this review. The recent Senate community affairs committee report made specific recommendations in this regard and again it is very relevant to a review focused on quality.
Ensuring there are transparent and workable processes in place to uphold standards and community expectations in terms of care is very important. The recommendations offered through this review will go a long way towards strengthening these. But a great deal of the issues relates to the corporate ownership structure of the RACFs. More specifically, the limitations that brings in terms of ensuring quality service provision.
Improving the lives of older Australians needs a firm policy focus and we’re starting to see that through this Minister. There is an opportunity to build off this review to fix some of those glaring issues limiting the quality of care. I’d like to see a stronger role prioritised for general practice and formalised in national policy. Limitations in terms of remuneration which also fail to capture the complexity of this care needs addressing. Valuing the role of the aged care workforce more broadly is central to ensuring quality outcomes. There’s so much more to be done here to ensure older Australians receive the care they deserve and we cannot afford to drop the focus on GP-led care solutions
10 November 2017
Dr Ayman Shenouda
PC Report: We can do better in health
The recently tabled Productivity Commission Report ‘Shifting the Dial: 5 year productivity review’ takes a broad policy lens on only on a few key areas which it states are likely to impact overall economic performance over the medium term. Health, of course, made it into this five-year review of the nation’s productivity alongside education and cities.
Overall the report turns to technology as an enabler for change and in parts more government control. The report suggests some major policy shifts to achieve a number of efficiency measures. Applying automation to healthcare as a cost reduction strategy specifically to achieve a smaller pharmacy workforce is one such shift. There are some familiar ideas floated throughout with many not pursued in the past for good reason. There is a lack of emphasis on the role of general practice in the health discussion which in turn weakens the piece.
A quick snapshot
While there are a number of recommendations for health against Healthier Australians many seem short on detail (and evidence). The sharpest shifts are pointed at education system reform, while health seems a little less disruptive. This is, of course, other than the recommendation for pharmacies to be turned into automatic dispensing outlets! In terms of the rest, well tackling those low-value healthcare procedures is really already in train and an important efficiency measure. Creating scorecards for the performance of providers to enable patients to compare outcomes is another idea which has merit but there are many higher priorities to pursue first.
There’s certainly a push to utilise more both the PHNs and LHNs to help overcome the federal and state funding standoff and related care gaps. This is both positive and problematic in terms of enabling integration. On one hand it will force more joining up through a funding means but on the other it will be reliant on forging strong relationships with general practice. The latter is not made a priority in this paper and instead implies more control (of general practice).
The paper states the need for a new funding pool for the PHNs and LHNs towards population health activities including some commissioning of GP services.There is certainly a need to create better structures and incentives to realign toward prevent and chronic disease management and localised solutions makes the most sense. However, the commissioning approach to procuring medical and health care services is still a work in progress in my view and much much more effort is required to engage general practice. That is the only way to establish trust and work through to those new ways of working in partnership with general practice.
The positives …
The overall positives of our healthcare system in terms of outcomes are at least acknowledged. We’re living longer, with less disability. Against OECD countries we have high overall health outcomes with the greatest life expectancy at birth. The third greatest life expectancy at birth in fact at 82.8 years (2015). On prevention and injury, we’re seeing a reduction in smoking rates and few deaths on our roads. And perhaps most importantly for a report focussed on fiscal pressures we’re spending less on health when compared to the other OECD countries.
And the negatives …
But holding us back, according to the report, noting this is from a perspective of lost productivity, are the 27.5% of adults who are obese and the 11 years spent in ill health which is the highest in the OECD. The last being despite having the third-highest life expectancy in the developed world.
It doesn’t hold back …
There are some scathing comments around some of the broader perceived negatives driving costs up. The comment in setting up the need to defund low-value healthcare procedures is both harsh and without (strong) cited evidence:
“Unjustified clinical variations, including the use of practices and medicines contraindicated by evidence, remain excessive, an indicator of inadequate diffusion of best practice, insufficient accountability by practitioners, and a permissive funding system that pays for low-value services.”
The example used here is knee arthroscopy which again is something we all knew about. The new Australian Commission on Safety and Quality in Health Care Standards developed to discourage the use of arthroscopy for patients with knee osteoarthritis is mentioned, yet criticised as it is an advisory and able to be ignored. The report cites some other examples to illustrate their concerns around quality: 75% of bronchitis treated with antibiotics, against best practice; and 27,500 hysterectomies without a diagnosis of cancer.
In finding efficiencies in health the report states:
“Doing better with our health resources can act as a safety valve for mounting fiscal pressures.”
This, of course, is quite obvious and not without (current) policy focus as finding healthcare efficiencies have really dominated the policy debate for nearly a decade. The report states that ‘some suggest that approximately 10 to 15 percent of health spending is used inefficiency due to poor quality care’. That last statement is (again) not referenced but let’s assume ‘some’ have stated it. We all know that the system is far from perfect but there are also many parts worth protecting including the gains realised in primary care. In this report, the efficiency measures are embedded in the detail, not necessarily making it to the recommendations and worth noting.
Observations on the detail
The report states that the patient experience of care receives little focus as a goal of the system. It accurately picks up some failures in terms of enabling choice – palliative care being one. But, it is in primary care where patient centred care remains core and where stronger gains have been realised. Particularly in terms of patient empowerment and ensuring prevention is prioritised and this is not really highlighted here. I really don’t think the review has reached out much at all to general practice, otherwise we would see this reflected more in the solutions.
I think the piece gets to the real issue where it states the current system encourages activity, not outcomes. It includes one of the strongest statements in this report:
“Australia’s messy suite of payments are largely accomplices of illness rather than wellness, only countered by the ingenuity and ethical beliefs of providers to swim against the current.”
From a primary care perspective, I agree that those limited MBS payments oriented towards preventative health and chronic disease are too narrow and inflexible limiting both outcomes and reach. But when considering other payment options, it worth remembering that general practice is a private business model and needs to remain as such. Whether that be maintaining fee-for-service combined with risk-adjusted capitation payments but particularly for pay-for-performance initiatives – ensuring continued practice viability must factor strongly. For this to work, pay-for-performance should only be used to drive quality improvement in certain priority areas – similarly to how the PIP currently operates - and be part of a mix of payment arrangements, not the sole driver.
The focus on enabling stronger integration is of course key and the stumbling blocks preventing more of it is put down to system deficiencies in the structure of our healthcare system – funding governance, linkages, and attitudes. More linking between PHNs and LHNs – fusing those government layers - at the regional level will achieve more integration. It’s about partnerships or more specifically, cultivating relationships between hospitals and GPs that will create these formal linkages to bring about stronger prevention, early intervention, and chronic disease management.
The word partnership is key here and for this to work we would need to see a genuine partnership with general practice, not seek to control it (as the earlier commentary suggests in imposing new funding models). This emphasis really highlights the greenness of this policy piece as it is general practice where the opportunities lie, yet so many opportunities have not been pursued here.
Reassuringly, this report also states that the solution is not to destroy the current system which it states would result in a policy adventure with many risks and uncertain outcomes. Instead, we should focus on those parts of the system already making that required shift towards a more integrated patient-centered system. Some might still say that this report takes us on a journey of (policy) misadventure. This might be true (in parts) but there are some areas worth testing.
Here's a short synopsis on the key recommendations
There are six key recommendations arranged against five identified problem areas – integrated care, patient-centered care, funding for health, quality of health and using information effectively. The recommendations:
2.1 Implement nimble funding arrangements at the regional level
2.2 Eliminate low-value health interventions
2.3 Make the patient the centre of care
2.4 Use information better
2.5 Embrace technology to change the pharmacy model
2.6 Amend alcohol taxation arrangements
I’ve hand-picked a few areas here.
The first recommendation (2.1), to implement nimble funding arrangements at the regional level, calls on all governments to allocation (modest) funding pools to PHNs and LHNs for improving population health, managing chronic conditions and reducing hospitalisation (at the regional level). This recommendation would provide a flexible fund to PHNs and LHNs to work through more localised solutions. It is the type of flexible funding solution we’ve called for in primary care for years but the enclosed word ‘modest’ is interesting.
This initiative builds on the PHN/LHN partnership discussion throughout the chapter and would help address some of the key barriers to integration. But, in my view, this would also require significant, not modest, funding levels to make a real difference and address current gaps impeding integration.
There are some real opportunities to pursue through general practice in order to address some of the clear service gaps or policy failures identified. Palliative care in the home being one of them. Building capacity of general practice in population health to invest in those preventive measures is another. The PHNs were sees an opportunity to enable more GP-led care particularly in preventive care and integration with the LHNs were already part of their remit. Therefore, this specific initiative is almost wholly reliant on general practice and it is disappointing not to see that emphasis made.
Eliminating low-value health interventions (2.2) states that progress to limit low or no-value services has been slow. There remain too many unjustified medical procedures (some we covered off earlier). The report also highlights that Australian procedure rates are markedly higher than other comparable OECD countries. There is also some discussion around patient expectations contributing and more broadly health literacy and the need for improvements there. Broader solutions include the faster development of clinical standards and ‘do not do lists’ by the ACSQHC. The report states that Medical Colleges should also disseminate best practice (which already occurs in general practice). De-funding (interventions) mechanisms as well as removing the tax rebate for private health insurance ancillaries is also discussed.
A key recommendation (2.3) to make the patient the centre of care is of course welcome. It is already a core value in general practice and expansion is really key to fixing our healthcare system. Empowerment measures including improving patient literacy and embedding patient-centered care in training all very important and picked up in this report.
The report highlights that ‘the OECD has characterised Australia as relatively poor in its capacity to collect and link health data’. As part of the solution, the PC suggests a new role for the ACSQHC in placing the patient front and centre. This would involve developing well-defined measures of patient experience of care. It would capture outcomes from a patient perspective to help build a picture of how the system is working at the grassroots level. I agree patient-reported outcomes measures or PROMs is important but this should only be used as a balance measure. Outcomes measures (high-level clinical), as well as process measures (evidence-based best practice in driving improvements), must continue to be prioritised if we have any chance of realising our health gains or goals over time.
Recommendation 2.4 (and 2.5)
Recommendation 2.4 picks up on this broader theme around data capture and related shifts in the previous recommendation. It calls for the establishment of the Office of the National Data Custodian. This change would help to ‘remove the current messy, partial and duplicated presentation of information and data, and provide easy access to health care data for providers, researchers, and consumers’. Much of the remaining parts to this recommendation sets up the requirement for a new model of pharmacy. The next recommendation (2.5) of course deals with the shift to pharmacy automation and The Pharmacy Guild of Australia’s response to it is worth reading.
The final recommendation (2.6) has a focus on public health initiatives and recommends moves towards an alcohol tax system. Interestingly, it falls short on measures to curb sugar intake despite the strong obesity emphasis throughout. Market control through voluntary reductions in sugar content (by major manufacturers of SSBs) is instead floated. This perhaps was one of the key areas worth exploring in enabling a more productive workforce and alleviating those 11 years spent in ill health. The report falls short here. I would welcome an expanded discussion including a stronger focus on physical activity as a key prevention measure.
For more information: Inquiry Report No. 84. Shifting the Dial: 5-year Productivity Review 3 August 2017
21 October 2017
Dr Ayman Shenouda
Health Education Accreditation
No case for change
Australia enjoys an enviable reputation as a provider of high-quality medical education and training. We have built a strong reputation for excellence and quality through a system of Australian Medical Council (AMC) led accreditation standards. A system that upholds patient safety and quality of care through high-level and targeted policy whereby accreditation indicators can be applied consistently has been key to our success. Yet the recent consultation with the release of a discussion paper as part of a Government-commissioned review into the accreditation systems suggests we have a system in need of strong repair.
The key shift proposed in the draft report involves the formation of more centralised control through a new Health Education Accreditation Board with an equally strong remit.
These would include:
The need to pursue such significant change at this time has confused many from within the sector. The specialist medical colleges through the Council of Presidents of Medical Colleges (CPMC) released a response early in the consultation. The Australian Doctors Federation (ADF) and Australian Medical Association (AMA) followed with strong resistance to such significant change to a system which is working well. All seem to agree that the key shift proposed in this paper would see the AMC’s role weakened leading to a dilution of standards and patient care. It would most certainly see unnecessary controls imposed on the specialist medical colleges.
Alignment or more bureaucracy
Major reviews usually share some common factors and this one is certainly not unique. These include the need for strengthened systems to improve outcomes and in driving efficiencies. It is a need for streamlining and alignment that make their way into most of these discussions. This in turn almost always means more government control.
The Accreditation Systems Review report states a need for alignment but then offers additional layers of bureaucracy to achieve it. It recommends increased government control over health professional education and training through the removal of the independence of the regulator. There is also a proposal to give the health ombudsman jurisdiction over specialist colleges particularly in relation to decisions around International Medical Graduates (IMGs).
Making a case for change
These key shifts are being floated as policy solutions ‘to ensure that the educational programs provide a sustainable registered health profession workforce that is flexible and responsive to the changing health needs of the Australian community’.
It is difficult to see how a large bureaucracy will drive system efficiencies and why you would seek more alignment beyond what already exists for medical education through the AMC. Specialty-specific requirements aligned towards patient need are key to determining quality outcomes. This expertise resides from within the specialist colleges and the AMC and will not be found through a bureaucracy-led board without any clinical discipline authority.
The draft paper seeks to introduce changes which really just stem out of a Productivity Commission Review undertaken more a decade ago. Given this review is being led by the same independent reviewer that’s not all that surprising. But it’s clear that much has happened since 2005 which gives, even more, reason for those ideas that were rejected once to be rejected now.
The draft report outlines the case for ‘Reforming governance – the overarching model’ presenting 3 options with their option 3 being the preferred model. Interestingly, all the recommendations within the chapter steer us toward this preferred option or model. It also includes a diagram of the model which does very little to clarify the role of the AMC in this new preferred structure.
It’s clear the discussion omits the fact that the AMC has led some significant reforms to provide a quality framework which delivers an outcomes-focussed approach to accreditation. This may be unintended but it is most relevant to many parts of the governance discussion.
In the last three years, the AMC committed itself to national and international review, to build on its strengths and develop and implement a range of new activities. Revised standards for specialist program accreditation were rolled out after a two-year review and consultation effort. Progressing the evaluation and deployment of a new accreditation management system that sees a more streamlined accreditation processes.  None of these get a mention yet they have been implemented to achieve many of the very aims outlined in this discussion. The fact is that the AMC has already implemented outcomes-based standards and it is working towards a more streamlined system.
Delivering a more responsive health workforce
Building on the recent AMC-led reforms through encouraging more inter-professional team-based learning is now key. Alignment can certainly be achieved through a stronger multidisciplinary approach and there remain plenty of barriers in the training system limiting us here. The report makes some good points around this issue. Ensuring our health workforce is more responsive to emerging health and social care issues and priorities through encompassing a stronger team-based approach is precisely where we need to focus our efforts now .
Driving key workforce priorities through our accreditation system through some of those key enablers identified throughout the report should be pursued. These include more use of simulation-based education and training in the delivery of programs of study as well as making mandatory the inclusion of inter-professional education in all accreditation standards. This more team-based approach to learning is most important enabling service alignment and it would be good to see it formalised in some way.
The other really important area for workforce policy is the requirement that clinical placements occur in a variety of settings, geographical locations and communities, with a focus on emerging workforce priorities and service reforms. This is particularly important to rural and remote communities and together with current workforce planning mechanisms will help ensure we can address unmet need. It will help build a rural GP generalist workforce prioritising essential rural advanced skill areas, procedural and non-procedural, in response to service and skill deficits. If planned appropriately – in prioritising skill need – then these shifts will help to rebalance training it current acute setting focus. This will help to prioritise funding to ensure more community-based exposure strengthening these service solutions over time which will bring about those required service reforms.
After deciding stakeholders needed a little longer to absorb the long draft report, an extension was granted with submissions having just closed (16 October). It will be interesting to see how this discussion evolves before a final report is considered by COAG Health Minister at their next Ministerial Council meeting in November. I think on many aspects this review failed to make the case for major reforms to governance particularly in light of the changes already implemented from a medical training perspective by the AMC. The real opportunity here is to build capacity from within the current structure to align skills to workforce need towards a more integrated national training solution.
In prioritising what needs to be done it is important to realise that we have an accreditation system which is working well. There is good reason why the AMC is internationally recognised for its work. We have the highest possible standards of medical education, training and practice already in Australia. The specialist colleges are key to ensuring we keep it that way through the delivery of high-quality specialist training. They also play a vital role in providing national oversight and consistency to medical specialist training. More dialogue was most certainly warranted before presenting such significant shifts. I hope the discussion moving forward brings a more balanced perspective encompassing the many areas of reform already achieved to build on these areas in ensuring a future workforce responsive to need.
 CPMC. Media Release. Australian Medical Regulation Must Remain Independent. Council of Presidents of Medical Colleges 2017. Available at: https://cpmc.edu.au/media-release/australian-medical-regulation-must-remain-independent/
 AHMAC. Australia’s Health Workforce: strengthening the education foundation. Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme for health professions.Draft Report September 2017. Australian Health Ministers’ Advisory Council 2017. Available at: http://www.coaghealthcouncil.gov.au/Portals/0/Accreditation%20Review%20Draft%20Report.pdf
 Productivity Commission 2005, Australia’s Health Workforce, Research Report, Canberra. Available at: http://www.pc.gov.au/inquiries/completed/health-workforce/report/healthworkforce.pdf
 AMC. Annual Report 2016. Australian Medical Council Limited. 2016. Available at: http://www.amc.org.au/files/656a1621bae0b8baaabca9e3ada8280a1dcbd38f_original.pdf
16 October 2017
Dr Ayman Shenouda
What really lies ahead?
While the impending changes from the Redesigning the Practice Incentives Program (PIP) still looms over us, among this deafening silence there’s concern around what lies ahead. It’s not so much the proposed changes to the PIP but more the underlying policy consequences in terms of broader payment reform and control over the profession.
The fee-for-service payment system remains the predominant commonwealth funding mechanism that assists patients to access primary care. The system is not well aligned to address chronic disease management and the complex health issues of our aging patient population. There is a need to find an optimal mix in addressing current need and future demand. We need funding mechanisms to tackle both complex chronic conditions and issues around disadvantage. Key is the priority shift toward improved patient outcomes and value, not just volume of service.
Key questions remain around what a value based primary health care system will look like. It will no doubt involve extensions of bureaucratic controls used to regulate professional practice with potential impacts on professional autonomy.
Health payment reform
The Government has not been shy in terms of its core focus on health payment reform in securing broader fiscal sustainability. However, in finding solutions, the policy jam seems well and truly fixed on finding savings from within one sector – from within primary care – despite it already being largely cost efficient.
Aspects of primary care payment reform alongside structural reforms are already being tested. The Health Care Homes’ voluntary trial, the Medicare Benefits Schedule (MBS) Review and to some extent the Primary Health Networks (PHNs) are key examples. These shifts have been occurring for some time and this latest redesign targeting PIP signals some further key changes.
The PIP redesign will see, even more, conditions imposed on general practice with an apparent shift toward imposing more funding controls through increased reporting. The policy lens again is on general practice where Medicare spending is value for money. Is this same focus being applied to the broader medical specialties? Driving prices down to regulate perceived skill based premiums might just bring some equity back into the discussion.
The QI measure
The key aim of the PIP is to support general practice activities in recognition of comprehensive, quality care. It provides a blended payment approach for general practices in addition to fee-for-service income. We know the most significant reform will be from the Quality Improvement (QI) measure which will require practices to collect full datasets alongside individualised targets for improvement.
The issue around who sets these targets is still a little unclear – self-selected or enforced. However, if the aim is to capture specifics of a practice’s patient population then I would suggest that the practice takes the lead here, not the bureaucracy. This in some way formalises a broader population health framework approach. This is positive but does a new QI measure involving data capture really provide the best way forward?
The rationale is around the use of data to measure and drive improvement. And certainly, no one is arguing that quality data on outcomes has not been lacking. Clearly, it has had its limitations and one would be around funding commitment to evaluation.
The long-term aim of the redesign is said to be around assisting practices to participate in quality improvement processes. Payments will be tiered to how this data has been used in terms of improvement measures. Those PIPs likely to be removed may well have already captured this detail. Data collection software storage adds a cost for practices but some already have these management systems in place, although not standardised.
There are two key issues here, the first around maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party (probably PHNs) QI provider. The second is broader intent which sees a likely shift towards a pay-for-performance scheme.
Maintaining clinical autonomy
Data control is, in fact, a real issue here. Maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party QI provider is one clear risk. Although utilising the PHNs as a vehicle for change could be beneficial it will require a partnership approach. They will need to further engage with GPs to establish the required trust and make sure they don’t encroach on clinical autonomy. Broader organisations who already do evaluation well and are trusted by the profession should also be brought in. Overall, GPs must remain free, within the parameters of evidence-based care, to make decisions that affect the clinical care they provide, rather than having these decisions imposed upon them.
There seems a move here towards a pay-for-performance scheme which in itself is problematic. Combined with an added data task resulting in more paperwork for GPs these requirements will risk taking our focus from patient care. Most practices have clinical risk management systems in place to analyse weak points and improve patient care. The PIP redesign consultation paper states that there is emerging evidence around a need for regionally-based change management to embed a quality improvement culture in general practice. This implies that GPs are inactive in this area when in fact the profession values and drives many of its own quality improvement measures.
There are already measures in place to support practices in undertaking QI activities. The RACGP QI&PD services offer a wealth of quality improvement tools and guides including clinical audit mechanisms. The College has developed a set of 14 clinical indicators to deal exclusively with the safety and quality of clinical care provided by Australian general practices.
Important unmeasurable factors
It is important to recognise that not everything can be measured. While clinical and organisational measures can be captured, there are other aspects of care important for healthcare quality which prove more problematic. Continuity of care and ease of access to care are unlikely to be captured in a neat format for the PIP QI measure. While attractive to funders pay-for-performance programs may not improve health outcomes or improve system quality. They have the potential to worsen overall care quality as focusing just on measurable outcomes takes us away from holistic general practice.
There is a much larger shift which needs to occur here and it won’t be achieved through a pay-for-performance system. In transforming health, we need to shift from reactive to proactive and predictive care. Early identification is the only way we can control rising chronic disease rates but our system relies on patient contact when they present with noticeable symptoms. Often this is just too late. We need a system which can take us across the spectrum of preventive care - from healthy to chronically ill -and priority measures for what falls between - for those at risk - to allow us to intervene early enough.
Finding the right mix for payment reform might involve encompassing bundled payments alongside some capitation. The latter being voluntary. The fee-for-service payment system should remain the primary source of funding for general practice services. While very tempting for Government, stable controllable costs should not dictate here. It is the patient that should remain the focus. More measures addressing out of pocket costs for GP services are needed.
The paradigm shift from a reactive sick care system towards a proactive and predictive healthcare model still seems a distant hope. While we’ve started the transition to restrain the demand for acute services through more focus on preventive care, finding that balance of funding for both acute and preventive care is not easy. This shift will bring about payment reform which can drive significant change for a more sustainable health care system and provide for a healthier future.
A preventive care PIP could have been brought in as part of this latest redesign as a way to boost funding and encourage new ways of working, yet that opportunity has not been pursued. Regardless, the new proposed PIP QI measure should only be undertaken initially as a trial. This could occur alongside the Healthcare Homes’ voluntary trial. The PIP measure needs to be contained to a sample location to truly test its capacity to deliver what it claims, rather than bring unnecessary disruption to practices through national release.
 AHHA. Bundled payments: Their role in Australian primary health care. Australian Healthcare & Hospitals Association. 2015. Available at: https://ahha.asn.au/sites/default/files/docs/policy-issue/bundled_payments_role_in_australian_primary_health_care_0.pdf
 PHCAG. Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care. Discussion Paper. 2015 Available at: https://www.health.gov.au/internet/main/publishing.nsf/Content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.pdf
 Duckett S. Opinion: Why it costs you so much to see a specialist — and what the Government should do about it. Grattan Institute. Published 14 August 2017. The Conversation Available at: http://www.abc.net.au/news/2017-08-14/why-it-costs-so-much-to-see-a-specialist-the-conversation/8803864
 RACGP. Standards for general practices (4th edition). Criterion 1.4.2 Clinical autonomy for general practitioners.Availableat:https://www.racgp.org.au/your-practice/standards/standards4thedition/practice-services/1-4/clinical-autonomy-for-general-practitioners/
 Australian Government Department of Health. Consultation Paper Redesigning the Practice Incentives Program. 2016.
 Wright M. Pay-for-performance programs. Do they improve the quality of primary care? AFP 2012;41:989-991. Available at: https://www.racgp.org.au/afp/2012/december/pay-for-performance-programs/
 MacIntosh E, Rajakulendran N, Khayat Z, Wise, N. MARS Blog: Transforming health: Shifting from reactive to proactive and predictive care. 2016. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
29 September 2017
Dr Ayman Shenouda
Cybersecurity in healthcare
The recent darknet Medicare breach came only a few months after the UK malware attack on the NHS locking its systems. You would expect the focus of authorities on potential threats to be high given the fallout from that. But we’re told the Government only became aware of the darknet issue from the media. And, that it had been there a while too: the data had been for sale on the darknet auction site for nearly nine months. So, while 75 Australians’ had their Medicare details sold, it appears neither the Department nor our security services were actively monitoring this posting.
We clearly need to get better at this. The Government had already demonstrated through the botched handling of the 2016 Census how unready it really was when it comes to predicting even the most predictable of attacks. The ABS website was crashed by a series of DDoS attacks which shut the census website down for nearly two days. Unfortunately, successive security and data breaches from government agencies like these only serve to undermine public trust.
Risks and benefits
Digitalisation of healthcare is a positive innovation but it comes with certain risks. It is a simple fact that the value of healthcare data makes our system more vulnerable to privacy breaches. You could say that publishing data of any kind potentially holds great risk to privacy. But certainly, the benefits in terms of service planning and health research outweigh those risks. It all comes down to how risks are managed so not to stifle policy or undermine public trust.
If we want to achieve a more integrated healthcare system then the only way forward is through enabling policies. The integration solution lies in policies such as those being pursued through the My Health Record.
We know the risk on our healthcare system and organisations through data theft attacks are becoming more common. As in health, prevention is always better than a cure and on this issue, the approach is the same. The focus here not only needs to be on how governments’ handle our personal information but how providers can be better supported to ensure organisational readiness.
My Health Record
There are a number of policy implications in terms of increased health information technology-based reforms. As the complexity of health services increase, the number of entities involved will increase and with that comes more risk around potential privacy breaches. We’re on the cusp of implementing long-awaited reform through the rollout of opt-out participation of the My Health Record system. It’s important to ask if this latest breach has shifted patients’ perceptions or altered their digital trust in moving forward on this policy.
We know that a Medicare card number alone is not enough to access a patient’s My Health Record. The official website reassures us that My Health Record is a secure online summary of a patient’s health information. That it is up to you what goes into it, and who is allowed to access it. While that last statement may be true, how well can this containment really be controlled?
Meanwhile, it seems take up in the pre-implementation phase of the opt-out My Health Record seems quite promising. The official stats show that almost 21 percent of Australians have already registered. The web page boasts that over 5 million people already have a My Health Record, with an average of 1 new record being created every 38 seconds. As with any good policy news, you can even follow progress with a helpful link provided: Keep up-to-date with the latest statistics on the My Health Record here.
Digital trust and implications for My Health Record
The Senate Finance and Public Administration References Committee Inquiry in August following the dark web breach has brought some new perspectives to the issue of digital trust. The 13 submissions provide some valuable insights, some of these I’ve summarised below.
The first cab off the rank, the Centre for Internet Safety, certainly didn’t hold back on the implementation of My Health Record. Stating that the shift to an opt-out system ‘has done little to quell public anxiety surrounding the placement of sensitive health details into the online world’. Critical also of the Government’s communication strategy which it says has not managed to convince on matters of security. This, combined with the constant reporting of breaches is all contributing to diminished trust, safety and confidence.
Their submission also states that the promotion of privacy issues and the importance of the protection of personal information is critical to the ongoing functioning of the online environment. To secure buy-in, it is important to create ‘benefit profiles’ alongside these new technology projects to truly test measures of ‘consumer trust, safety and confidence in the intended service delivery’. In terms of My Health Records, they warn uptake will be very slow unless the Department can adequately address the trust, safety and confidence benefits and competently communicate these to the public.
The Australian Information Commissioner’s input provided some useful guidance stating that ‘the use of personal information should be necessary, proportionate and reasonable to achieve the policy goals’. The Privacy Impact Assessment (PIA) is a policy tool designed to assist agencies to consider these matters measuring possible impacts on the privacy of individuals. The Commissioner stated that, in the case of the Medicare breach, a PIA would have highlighted privacy impacts associated with assessing Medicare care numbers through an online portal environment. Importantly, it would have identified any further proactive measures required to mitigate those impacts.
Both the RACGP and the AMA do not believe this latest breach will have any implications for the My Health Record roll-out. The University of Western Australia, while outlining the value of Medicare identification information to a criminal – identity fraud, prescriptions to obtain painkillers and possibly S8 medications as well as to divert Medicare rebate payments from a legitimate account to a false one - also state motivations to access to My Health Records or medical records of any kind as being less likely.
Importantly, the RACGP highlighted that even with preventative measures in place, real risks persist for any organisation in terms of internal or external data breaches in an interconnected world. There are College resources to support GPs to minimise risks including the RACGP Computer information security standards (CISS). It states that those practices implementing the cybersecurity and privacy guidance provided here are less vulnerable to a data breach.
Both the Department of Health and the System Operator of the My Health Record System, the Australian Digital Health Agency, state that is important to note that illegally obtained Medicare card numbers are not sufficient on their own to provide access to clinical records or an individual’s My Health Record.
The System Operator appropriately provides a detailed response to the impact on the rollout from the Medicare information breach. Reassuringly, it states that security and operation of the system protect against the unauthorised disclosure of health information from the My Health Records for individuals with access to Medicare numbers. Additional information is required to authenticate consumers and healthcare providers. But, despite these reassurances, it is clear in other submissions including those from the University of Melbourne, Deakin University and the University of Newcastle that concerns remain with the My Health Record system and its pending rollout. Future Wise give an excellent technical response to the issue as well as policy solutions in moving forward.
The policy lessons
It is important to see the risks in terms of potential implications to the rollout of the opt-out My Health Record system tested through this consultation. It will be interesting to see what recommendations are made in the Senate Finance and Public Administration References Committee Inquiry in its report due in October. Overall, I think more work needs to be done here with much more focus required on strategies to protect patient data in rebuilding trust.
From these consultations, mechanisms for overseeing and monitoring access seem lacking, so are the required assurances around data storage and controls and the system-wide capacity to provide the security controls to mitigate risks remain unconvincing. The collective wisdom provided in these submissions will help guide policy to safeguard from further threats in the future. As stated earlier, the success of important reforms including My Health Record comes down to how risks are managed so not to stifle policy or undermine public trust.
 Yaraghi N. Hackers, phishers, and disappearing thumb drives: Lessons learned from major health care data breaches. Centre for Technology Innovation at Brookings. May 2016. Available from: http://wikiurls.com/?https://www.brookings.edu/research/hackers-phishers-and-disappearing-thumb-drives-lessons-learned-from-major-health-care-data-breaches/
Changing our healthcare system starts in the consulting room
15 September 2017
Dr Ayman Shenouda
There’s been a lot of discussion around empowering the patient more in their treatment decisions. That we need to shift our focus toward a system that empowers and facilitates choice. But undermining a shared decision-making model – one which has room to provide for both clinical choice and patient choice – is our healthcare system. We have a system which is based on a disease-based model of care which leaves little room to take into account the context of the patient's illness. A system that can allow us to refocus on the patient-centered, personal and unique experience of “illness” must be prioritised.
Patient experience in the health system is so vitally important and has to be valued. For me, changing our healthcare system really starts in the consulting room. It’s that doctor-patient relationship that I really value. And this often goes unnoticed by our decision makers – but it is here where lasting change can be realised. Discussions in general practice are of great value for helping patients take charge of their own health. A more focussed effort here not only helps to improve health but will support quality reform measures which can reduce costs.
Research shows us the benefits of a shared decision-making model approach. These include knowledge gain by patients, more confidence in decisions, and more active patient involvement. Studies have shown that, in many cases, informed patients elect for more conservative treatment options.
Preparing for the challenges ahead
The health system cannot cope with what it is facing. Health care demand on the system is reaching crisis point with public spending at unsustainable levels. Empowering patients is most certainly part of the solution if we are ever going to meet rising demand with an ageing population. But to do this, empowerment needs to be met with a system that can facilitate choice.
Recently I attended an event organised by the RACGP NSW Faculty delivered by an ICU Physician who led an impressive discussion around frailty. He spoke about the elderly intensive care unit (ICU) patient and poor outcomes. More specifically, the need to identify frail patients at high risk of poor outcomes and plan accordingly.
We were brought across a study which investigated the effects of frailty on clinical outcomes of patients in an ICU. It used a frailty index (FI) which was derived from comprehensive geriatric assessment parameters. It found that the use of a FI could be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs. Another study found frailty is common in patients admitted to ICU and is associated with worsened outcomes. It recommended that this vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans.
Identifying patients at high risk of poor outcomes is key here. But the system cannot identify what frail means, nor does it empower GP decision making at the cold face. Applying the FI is one way to ensure we’re not placing patients where there is no real benefit. But the culture within hospitals makes it hard to implement this tool. Enabling end-of-life discussions particularly at a point when there is a crisis situation is also a barrier.
Planning for end of life and putting in place an Advance Care Plan early is essential. GPs are very good at this. It should be undertaken as part of the Over-75 Health Check. and helps equip the patient, and their family, well for what lies ahead. It’s a good time to talk to the patient about prevention, maintaining functionality, minimising pain or complexity of disease as well as strategies to address them. It is also time to start the discussion around being frail and their expectations around that.
High price for poor outcomes
We know that more than 30 percent of patients admitted to intensive care units never make it out. Those that do rarely make it back to their own home. It costs around $4,000 per night in ICU . This spend can be better utilised if redirected to support patients in their own home.
I know from my own elderly patients’ experience that it is often hard for the patient not to end up in ICU. The system makes it hard to facilitate this care in the community. And it’s hard to take on the system during a crisis. It takes a strong family who is across their loved one's wishes.
Care in the community
I recall consulting at my surgery in The Rock some years ago and receiving an urgent phone call. It was the daughter of my 82-year-old patient and she needed my help in preventing the transfer of her mother from Wagga Base to Sydney. She told me the specialist was transferring her and that the family did not want her to go through this and that her mum didn’t want this either. They understood that their mum was in a critical condition but wanted her close to home.
I immediately made the call to the Specialist Respiratory Physician who explained she had a flouting clot in her pulmonary artery and needed an embolectomy and a filter in her IVC. The specialist had already discussed her case with the Cardiothoracic Surgeon in Sydney and organised the transfer. I explained that the family had called and that this was not what my patient, nor her family, wanted. I also explained that I was prepared to look after her in the community. Fortunately, the specialist at Wagga was comfortable provided she sign a discharge against medical advice.
This patient lived for a further five years. She was able to attend her grandson’s wedding in Sydney two years before she died peacefully at her home with her family around her. A testament to her strength and also that of her family. They ensured she stayed in Wagga to receive care an appropriate level of care in the community. They insisted that she was not transferred to a Sydney hospital where she was likely to end up in ICU and never to come home.
Making the system work
How can we ensure that the system can default to enable care in the community, rather than automatically preference for tertiary care? While there exists a frailty tool there’s reluctance to use it. There’s plenty of GPs happy to care for their patients in the community if that’s their choice. But rarely will the patient’s GP be consulted at that critical stage. There is also limited funding to facilitate this care.
A reality check is well-overdue in terms of outcomes particularly in dealing with the frail. We’re missing the point on where to focus care. This needs to be where there is the greater need and where the efficiencies can be found. And this is not on a system which is disease focussed and already crippled by expensive treatments. To prevent waste, more realistic expectations around outcomes can be achieved through person centred care enabling empowerment. One of the strengths of general practice is the unique relationship between patients and their GPs. Patient centred communication and shared decision making is the foundation on which our health system can be remodelled. Let’s prioritise it.
 Green AR, Carrillo JE, Betancourt JR. Why the disease-based model of medicine fails our patients. Western Journal of Medicine. 2002;176(2):141-143.
 Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner, M Llewellyn-Thomas, H Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011;as well as(10):CD001431.
 Kizilarslanoglu, M.C., Civelek, R., Kilic, M.K. et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res (2017) 29: 247. https://doi.org/10.1007/s40520-016-0557-y
 Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Medicine (2017). 43: 1105.https://doi.org/10.1007/s00134-017-4867-0
Health sector reform: towards a sustainable system.
8 September 2017
Dr Ayman Shenouda
A decade of reform
We’ve had a multitude of reforms over the past decade or so with much of it stemming from the National Health and Hospitals Reform Commission (NHHRC). A strengthened consumer voice and empowerment was perhaps the most important shift in the reform discussion at that time. A shift which held great promise in realising change through a more patient-centred approach and one which prioritised primary care and its role in achieving the required shifts.
During the NHHRC years of review, significant structural reform was recommended including in terms of responsibility for primary health care services as well as a more transparent and equitable funding model for public hospitals. The latter has seen some sizeable shifts, particularly in the way we determine funding to public hospitals through the introduction of activity-based funding.
We’ve seen other changes too in formalising shared policy commitment in the form of National Partnership Agreements to help set and agree upon priorities and measure progress across a range of areas.
Structure reform requirements
It’s clear that much has been done to improve the performance of Australia’s health system. But after years of review and with policy fatigue well and truly set in are we any closer to a framework which will secure the future sustainability of Australia’s health system?
Key to realising patient-centred health policy lies in structural reform to promote more integrated care. Our past attempts haven’t brought us much closer to realising this clear requirement, noting we are still implementing much of it as many reforms are ongoing. Information Technology provides certain opportunity here. The My Health Record (formerly PCEHR), as one key measure, is still being implemented and yet to deliver on its promise. As it transitions towards the planned opt-out phase mid-2018 there is still much hope that it will succeed.
Organising primary care through a medical home model of care would also support integration and provide patients with continuous, accessible, high-quality and patient-centred care. Australian general practice encapsulates the medical home model, and a supported policy shift here, if funded appropriately, together with further incentives to promote integrated care across different care settings, would bring us closer to the level of reform required to address current and future demand.
But fragmentation in health care structure exists largely due to the primary and secondary care divide. Each which is then further complicated by its own arrangements through compartmentalised funding streams. This, of course, leaves little to no room to integrate at least not to the level we need to.
Complex governance structure
It’s clear that system complexities brought about by a governance structure with responsibilities falling between the Commonwealth and the states and territories have not served the health consumer well. It’s hard to navigate and even harder for patients with complex or multiple illness or disease.
Bringing the responsibility for acute and primary care together at one level of government is one clear solution. Devolving primary care to the states and territories might just help provide the structures and incentives needed to promote integration. A way forward might be in the form of a state-level trial to integrate local hospitals and health services with primary health networks piloting integrated models in one health service/local health district.
Integrated funding and management have been suggested before, many times in fact and it wasn’t that long ago that we had a serious discussion around it from former Prime Minister Rudd, although with a Commonwealth dominated role in mind.
More recent discussions lead to a similar conclusion, that a move to a single or pooled source of government funding would help to eliminate bureaucratic cost shifting and duplication. This alongside more private sector contributions and alignment to outcomes. Integrated funding and management is one of five central policy levers available to reform Australia’s health system. The other four are around consumer empowerment and responsibility; wellness and prevention; optimised care pathways; and information-enabled health networks. 
Making it better
It is important to acknowledge that Australia has a strong system of healthcare. A high-quality universal healthcare system with coverage through Medicare to the main components of care extending across public hospitals, medical services and pharmaceuticals. The Commonwealth remains the dominant policy maker, which is due to the simple fact that it generates most of the funding. There is a complex division of roles and responsibilities across levels of government with the involvement of both public and private sectors.
The financial dependency of the states on the Commonwealth makes it harder for them to lead in this area. The required focus on outcomes likely to become a bit blurred when it is confined to funding limits and controls imposed by it. While there may exist a shared policy objective - whether that is to help people sustain and improve their health or improving quality or even equity in access - in attaining those measurable outcomes compromise is always tied to the narrow confines of what has been negotiated.
It seems the way forward comes back to a question around who’s best positioned to lead? The current division of responsibilities and roles across levels of government impacts significantly. Devolution of responsibility and funding to one level should be tested to see if integrated funding translates to integrated delivery. If we can move beyond the control being where most of the funding is generated for one moment then we might get a little closer to fixing our fragmented system. This is where we remain stuck and unless tackled we will not move forward.
 The Royal Australian College of General Practitioners. What is General Practice? Melbourne: RACGP; 2012. Available at www.racgp.org.au/becomingagp/what-is-a-gp/what-is-general-practice
 Bartlett C, Butler S, Haines L. Reimaging Health Reform in Australia. Taking a systems approach to health and wellness. PwC; 2016 Australia. Available at: https://www.strategyand.pwc.com/reports/health-reform-australia
 OECD Health Policy Overview. Health Policy in Australia. OECD; 2015. Available at: http://www.oecd.org/australia/Health-Policy-in-Australia-December-2015.pdf
 PwC 2016, op. cit., p. 22.
 PwC 2016, op. cit., p. 8.
 The Commonwealth Fund. Health Care System and Health Policy in Australia. Available at: http://www.commonwealthfund.org/grants-and-fellowships/fellowships/australian-american-health-policy-fellowship/health-care-system-and-health-policy-in-australia
In overcoming significant disadvantage, it is the capacity of the general practice workforce that will provide the biggest impacts in realising improved health outcomes over time. General practice is by far the most efficient and cost-effective part of the healthcare system. GPs are often relied on the most, particularly by those most in need and with complex and chronic conditions.
General practice is already an efficient part of the healthcare system. GPs also have a very large remit. In any given year, almost all Australians – or 85 per cent – will visit a GP at least once. Yet government expenditure on general practice is relatively low at around $6.8 billion, under 5 per cent, of total recurrent health spending.[i] When compared to the significant cost to the sector for hospital services - expenditure on public hospital services is at around $61 billion – general practice offers value for money.[ii]
There is clear global evidence that health systems with strong primary care will secure long term efficiencies. Benefits from prioritised investment include achieving lower rates of hospitalisation, fewer health inequities and better health outcomes including lower mortality. The findings captured by Starfield for one make a convincing case for primary care investment and are not new, but so do so many studies that have followed it.[iii] [iv]
A broader population health policy framework that recognises the role of primary care and general practitioners in addressing health disparities makes really good policy sense. But how do we convince our policy makers – firmly fixed within their short-term electoral cycles and need for quick wins - that a strong investment now will provide real and significant returns for a healthier future?
It’s clear that policy makers are not short on evidence around the benefits of prioritising these areas. These are critical funding decisions that impact quality, access, and coordination of health service delivery.
There is significant unmet need with access to primary health care still one of the main barriers to achieving equitable health outcomes. This is the case for many disadvantaged Australians and certainly for Aboriginal and Torres Strait Islander communities. National studies have shown that health outcomes improve with improved access to GPs in areas with relatively high predicted need for primary health care.[v] But we are not seeing anywhere near the level of investment needed to make the shifts required in supporting those most in need.
Embedding more preventative health interventions in the primary health care setting also needs focus. Primary care and preventative health go hand in hand. A rising disease burden requires a stronger emphasis on preventative health and GPs are key in terms of delivery. We clearly need to be prioritising both areas and with the level of investment warranted to secure strong health outcomes. We need investment in both prevention and primary care with recognition through funding of the important role general practice has in delivering both aims.
While preventative health requires a whole of community focus and an effort from each and every one of us, much of the service responsibility again falls to general practice. The GP has the lead role in ensuring their patients remain healthy over a lifetime and preventing illness, identifying risk and offering early intervention is already a large part of what we do.
I know firsthand that our patients most certainly value general practice and understand well the need for prevention and for real investments around that beyond just a health message. Research Australia’s annual Health and Medical Research public opinion poll ranked preventative health as one of the nation’s key health priorities. More than 75 per cent of Australians ranked preventative health as a key priority in 2016.
In determining health priorities, that role now falls to the Primary Health Networks and their focus in six priority areas: Aboriginal health, aged care, e-health, mental health, population health and health workforce.[vi] However, we know that issues around equity and social determinants of health is key to shifting entrenched disadvantage. The much broader set of objectives in our National Primary Care Framework (April 2013) should be revisited. Clear aims to drive our funding decisions which included a focus on addressing inequity in keeping all Australians healthy, preventing illness as well as reduce unnecessary hospital presentations and making improvements in the management of complex and chronic conditions.[vii]
To drive the level of change general practice needs to be better resourced. Investment needs to prioritise general practice and build upon existing services and arrangements. An investment which will lead to improved health outcomes, better management of chronic disease, a stronger focus on prevention and lower rates of unnecessary hospital admissions. A strong investment in general practice is what is needed to secure a healthier future for all Australians. The lift of the freeze, albeit slowly, is welcomed, but this only puts us back where we were at in 2013 before it was introduced. Let’s get the full discussion back on track. Let’s pick up where we were at nearly a decade ago when we were on the cusp of significant reform in Australia. A reform which saw a priority on general practice and its role in prevention and primary care.
[i] Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014–15. General practice series no. 38. Sydney: Sydney University Press, 2015. Available at http://hdl.handle.net/2123/13765
[ii] AIHW 2017. Australia's hospitals at a glance 2015–16. Health services series no 77. Cat. no. HSE 189. Canberra: AIHW.
[iii] Starfield, B., Shi, L. and Macinko, J. (2005), Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 83: 457–502. doi: 10.1111/j.1468-0009.2005.00409.x
[iv] Harris MF, Harris E. Facing the challenges: general practice in 2020. Med J Aust 2006; 185: 122-124.
[v] Australian Institute of Health and Welfare. 2014. Access to primary health care relative to need for Indigenous Australians. Cat. no. IHW 128. Canberra: AIHW.http://www.aihw.gov.au/publication-detail/?id=60129547987
[vi] The Department of Health. Primary Health Networks (PHNs). Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Background
[vii]Commonwealth ofAustralia.NationalPrimaryHealthCareStrategicFramework.2013.Availableat: http://www.health.gov.au/internet/main/publishing.nsf/Content/6084A04118674329CA257BF0001A349E/$File/NPHCframe.pdf