AMA response to the consultation draft National Primary Health Care Strategic Framework

11 Oct 2012

National Primary Health Care Strategic Framework – Consultation Draft

The AMA has made comments on the National Primary Health Care Strategic Framework Consultation Draft released by the Commonwealth Government (and prepared with State and Territory governments under the National Reform Agreement).

The AMA supports measures to improve primary health care in Australia and maintain a GP-led primary health care model. The AMA has expressed concern that the draft Framework makes no new funding available in primary health care while expecting the primary health care system to take further pressure off the public hospital system.

The submission makes some general comments and then addresses the four specific questions outlined in the consultation draft cover sheet.

General comments

Firstly, the AMA supports the efforts of the Commonwealth and State/Territory governments to consider ways to improve primary health care in Australia.  However, the AMA does not support a starting point of no new additional funding for a National Primary Health Care Strategic Framework as realistic or workable.  The Australian Government’s National Health Reform document Improving Primary Health Care for All Australians states:

Under National Health Reform, the Commonwealth government is aiming to shift the center of gravity of the health system from hospitals to primary health care…Under the Commonwealth Government’s National Health Reform, the Commonwealth will fund 50% of growth in the efficient price and service provision in public hospitals. This will provide a powerful incentive to the Commonwealth to ensure we make better use of primary health care services to ease the strain on public hospitals.1

From the AMA perspective, it does not make any sense to be stating that the centre of gravity in health care is going to shift to primary care to take pressure off the hospital sector and expect that this can be done within existing resources in primary health care.  

The AMA supports the view that investment in primary health care has exponential benefits in reducing pressure in the hospital sector (i.e. what is spent in primary care will lead to much bigger savings downstream in the health system). However, this does require some investment – downstream savings cannot be realised without proper investment at the front end.

As a second general point, the AMA supports the recognition within the draft National Primary Health Care Strategic Framework that general practice is the foundation of good primary health care in Australia.  A strong GP-led primary health care system keeps people well and saves lives.  GPs and their patients have long held the view that having a good relationship with a GP and a link to a particular general practice (a medical home) is highly valued and one of the features of the Australian primary health system which should be supported and encouraged.  The AMA considers this relationship between patients and GPs is developed over time and based on trust and does not warrant formalisation through systems like patient enrolment that would not value-add to the current system.  

The AMA notes that at the recent face-to-face consultation on this draft National Primary Health Care Strategic Framework, some groups did not appear to understand the concept or value of a GP-based medical home and the benefits it provides to all primary health care provision.  The AMA considers that the initial and uninformed responses from other groups do not reflect what patients want and expect from their primary health care providers.  The concept of a medical home with a chosen GP or general practice is part and parcel of the Australian experience of primary health care and needs to be retained in any Framework about primary health care’s future.

Addressing the Four Questions in the National Primary Health Care Strategic Framework Consultation Draft Coversheet

1. How can the Framework add the most value to:

a.the primary health care system

In its current form, the document attempts to be both high level and a document that includes some specific proposals for potential changes to the primary health care system. The AMA considers that the document and the thinking behind the document should not try to do both.

If the document is high level with general objectives and overarching strategies, then in consultation with stakeholders the details to achieve these objectives can be worked out over time.

On the other hand, if the Framework is going to have a lot of detail about possible changes of direction in primary health care in Australia, these details need to be discussed and agreed with relevant stakeholders who actually deliver primary health care in Australia before the document is finalised.  Otherwise, the exercise is a waste of time.  While Commonwealth and State and Territory governments do have policy and funding oversight in how primary care is delivered in Australia, the reality is that what people actually experience when it comes to primary health care happens at the coalface – in doctors’ surgeries and community health centres.

When defining primary health care in Australia (noting particularly the outline on page 6), the focus centres on government responsibility for funding and policy development. This does not actually describe primary health care in Australia and it certainly does not sufficiently recognise the role of private primary health care providers. As such it gives an inadequate picture and creates misleading expectations about what government can do or should do. Later on page 11, the draft Framework reads:

Commonwealth and state governments must work together to ensure the ongoing improvement and sustainability of the primary health care system with the goal of ensuring effective, safe services for consumers aimed at providing care in the most appropriate and efficient setting, and improving health outcomes.

This could be interpreted to read that governments alone have the power and capacity to improve the primary health care system. It simply does not recognise that governments cannot do anything in the primary health care space without the health providers in the field supporting positive changes or policy directions.

1. How can the Framework add the most value to:

b.the health system more broadly?

The document seems to imply that some of the problems in the health system can be attributed to primary health care in isolation from the rest of the health system.  For example, on page 3 it states:

However, in Australia the complex interaction of Commonwealth and state/public and private services in primary care often operate in an uncoordinated and poorly integrated fashion, resulting in fragmentation and gaps in services, and less than optimal outcomes for consumers.  Under this framework, the Commonwealth and States will adopt a new model of working partnership to integrate care across care settings and improve health outcomes.

The AMA is not convinced that the fragmentation and gaps exist so much within primary health care as between primary care and other parts of the health system such as secondary and tertiary care.  Many GPs have reported their frustrations about the disconnect that sometimes occurs between primary health care and in particular public and private hospitals.  A well-developed and clinician friendly e-health system would go a long way to addressing many of these concerns but a fundamental tenet and priority should be given to improving the communication between the various parts of the health system.  Further, the MBS fee structure needs to reflect that it takes time and clinical input to communicate effectively across various parts of the health sector.  

Communication between the primary and acute sectors needs to be appropriate, accurate and timely so that patients experience a seamless journey within the health system.  When the communication is not appropriate, accurate and timely – it is one of the greatest hindrances to the prevention of avoidable hospital presentations. Public and private hospitals need to develop processes to ensure that discharge summaries, outpatients’ letters and other communication about patients are provided to GPs to enable good continuity of care.  Hospitals are under pressure and do not always see this as a high priority and yet, the consequence of not making this a priority is that the primary health care provided to patients after hospital discharge is not as optimal as it should be, and of course as previously mentioned is often the cause of hospital readmission.

2. How can the framework maximise patient health outcomes and experiences?

The draft document has a section on the systemic national challenges in health care starting on page 8 of the document.  This section starts by saying that Australians enjoy some of the best health outcomes in the world and then goes on (quite rightly) to outline that some groups do not enjoy equitable health benefits.  However, the Framework does not go on to specifically address how the groups mentioned would be targeted for better primary health care.  It is clear that these groups need further targeting as this is where some gains can be made in improving patient health outcomes and experiences and therefore the strategic framework needs to make mention of the strategies that will be used to improve primary health care for these particular groups. 

E-health

One of the biggest reforms currently in train that has the potential to improve patient health outcomes and experiences is in the area of technology and e-health.  As you would be aware, the AMA has been a vocal critic of many of the components of the Personally Controlled Electronic Health Record (PCEHR) in its current form.  While the AMA considers that the PCEHR has the potential over the long term to assist with pathways and improve coordination of care, the PCEHR itself also has significant limitations built into its design (e.g. opt-in and the patient’s ability to control what information is on the record).  This will limit its effectiveness and the potential benefits to patients and the downstream benefits for the health care system.  When clinicians do not trust the content of the e-health records, they will not use them and all the potential that could have been gained from a well-developed system will be lost.  

E-health is one of the key areas where linkages between the primary and acute care sectors can be made.  The AMA considers that any National Primary Health Care Strategic Framework must address in detail what needs to happen to ensure that the PCEHR and any other e-health initiatives are supported by GPs and general practices and well integrated into primary care.  The simple fact is that if GPs and their practices do not support the government-funded e-health initiatives, they will not work and all of that potential gain of linking primary health care with other parts of the health system will be deficient and a waste of health resources. 

Team Based Care

The draft Framework acknowledges the role of multidisciplinary teams in which all team members are supported to fully develop their clinical skills within their scopes of practice.  The AMA has always acknowledged the positive role that well-functioning GP-led multidisciplinary teams can have in the primary health care setting.  At the same time, there is no substantive evidence that shows that nurses and allied health professionals working independently of GPs can deliver the same quality health care outcomes as the team-based model of primary health care delivery that is supported by the AMA and is currently established in Australia.

Many years of intensive study, specific training and experience underpins the breadth of skills and knowledge that give patients the holistic care that specialist general practitioners provide.  There are no shortcuts.  Therefore, the AMA supports the Framework’s acknowledgement of primary health care multi-disciplinary teams but cautions against any references that may be construed as GP role substitution by other health professionals. 

Invest in GP consultations

GPs provide all the care needed for 90% of the problems they encounter and in addition GPs account for less than one tenth of per capita expenditure on health.  In other words, the services provided by GPs provide very good value for money and are an efficient means of ulitising scarce health dollars.

Further, the increasing burden of chronic disease has a significant cost impact on Australia's health system. Fifty percent of GP consultations involve patients with a chronic disease, such as heart disease, cancer or diabetes. This cost of chronic disease is further added to with at least 10% of hospitals stays for patients with chronic conditions potentially preventable should timely and adequate non-hospital health care been provided.  This again demonstrates that investing in primary health care can lead to much better patient outcomes and significant downstream savings in other parts of the health system.  

Patients will get the best quality care when decisions about their health care are made according to their clinical need.  To effectively tackle chronic disease, GP items in the Medicare Benefits Schedule (MBS) need to be simplified and have a fee structure that encourages longer consultations.  This would support GPs to engage in preventative health care and take the time needed to communicate with other parts of the health system.  Unless patients with complex and chronic disease are given a rebate that allows them to spend time with their GP, they may not be able to afford the treatment they need.

The evidence shows that, if GPs are able to spend more time with each patient, they keep people healthier and reduce the burden on other parts of the health system.  (See under the response to question 4 for references to the AMA’s Chronic Disease Plan).

Reform of the MBS must address the need for patient rebates to be properly indexed so that they keep up with the rising costs of health care.  Failure to properly index patient rebates simply means that over time the costs of health care are transferred from the Commonwealth to the patient.

A National Primary Health Care Strategic Framework that does not address how the current MBS system can be improved to ensure patients get the primary health care they need from their GP is simply deficient. 

3. How can governments strengthen partnerships with stakeholders to deliver the strategic outcomes (discussed above)?

As mentioned at the beginning of this response, the Framework should be either high level or a detailed plan for the future.   If the document is high level with general objectives and overarching strategies, then in consultation with stakeholders the details to achieve these objectives can be worked out over time.  If, however, the Framework must include more detailed initiatives then these need to be discussed and agreed with relevant stakeholders who actually deliver primary care in Australia before it is finalised.  

The AMA notes that a number of controversial issues have been raised in the draft Framework including:

  • blended payments systems mixing fee for service;
  • pre-payments and payment for performance with salaried arrangements;and
  • development of performance indicators, which identify circumstances in which consumers may not be receiving the most appropriate care.

The AMA considers that it is inappropriate to give passing references to highly contentious changes such as the ones listed above. This devalues the Framework as the references are not explained in any detail, contestable and clearly not considered/agreed by stakeholders. These would be major areas of reform and are highly controversial particularly in light of the starting premise of no new resources for the Framework to be implemented.

4. When considering implementation of the Framework:

a. What relevant activities are stakeholders delivering that governments could learn from?

b. Do you have any new or innovative ideas that could be incorporated?

In 2008, the AMA released General Practice in Primary Care: Responding to Patient Needs – An AMA Blueprint for the delivery of primary health care services in Australia. While it has been a few years since this document was drafted and released, a considerable amount of research and thinking went into preparing this document and outlining strategies for improving primary health care in Australia.  The findings of this document are still relevant today and a copy of this blueprint is attached for your consideration.

In addition, the draft National Primary Health Care Strategic Framework recognises that one of the greatest challenges in Australia’s primary health care system (particularly the link to avoiding hospitalisations) relates to patients with complex or chronic care needs. The AMA has developed the AMA Chronic Disease Plan: Improving Care for Patients with Chronic and Complex Care Needs – Revised 2012. The AMA’s plan builds on existing MBS items with streamlined access to allied health and other services across levels of care relevant to the complexity of the patients’ needs.  The AMA’s plan provides for enhanced access to a broader range of services, including the services of a care coordinator for those patients with chronic and complex disease that need greater support and are at risk of a preventable hospital admission. 

A copy of the AMA’s Chronic Disease Plan is also attached for your consideration.

If you have any queries or seek clarification about any of the issues raised in this response to the draft National Primary Health Care Strategic Framework, please contact Mr Warwick Hough, Senior Manager, General Practice, Legal Services and Workplace Policy Department, ph: 6270 5488 or email whough@ama.com.au


1 Australian Government, 2011, Improving Primary Health Care for All Australians, Canberra: Commonwealth of Australia, pp1-2.