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.[1] Key is the priority shift toward improved patient outcomes and value, not just volume of service.[2] 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.[3] 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.[4] 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.[5] 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.[6] 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.[7] 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. Conclusion 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. [1] 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 [2] 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 [3] 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 [4] 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/ [5] Australian Government Department of Health. Consultation Paper Redesigning the Practice Incentives Program. 2016. [6] 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/ [7] 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/
0 Comments
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.[1] 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.[2] 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. [1]https://www.theguardian.com/australia-news/2017/jul/08/data-breaches-undermine-trust-in-governments-ability-to-protect-our-information [2] 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 Empowerment 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.[1] 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.[2] 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.[3] 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.[4] 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. [1] 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. [2] 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. [3] 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 [4] 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[1], 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.[2] 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.[3] 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.[4] 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. [5] 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.[6] 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. [1] 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 [2] 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 [3] OECD Health Policy Overview. Health Policy in Australia. OECD; 2015. Available at: http://www.oecd.org/australia/Health-Policy-in-Australia-December-2015.pdf [4] PwC 2016, op. cit., p. 22. [5] PwC 2016, op. cit., p. 8. [6] 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. [ends] [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 |
Author
Dr Ayman Shenouda Blogs categories
All
|