Dr Bartone - Speech - The changing primary care landscape

20 Sep 2019







***Check against delivery

The changing primary care landscape

Good morning.

I acknowledge the traditional owners of the land on which we meet, and pay my respects to their elders, past and present.

Thank you to AHPA for the opportunity to address this Symposium today.

We all acknowledge it is a very important time for our primary health care and for our health care system in garner.

It is four months since the Federal election, and we are all still waiting for some indication of where we are headed on significant much-needed reform in the health system.

The AMA has been long calling for an overarching long-term vision for health care in this country. We called for it loudly during the election. We are yet to see one. We need one.

Our healthcare system is hostage to the triple drivers of increasing population, an aging population, and increased incidence of chronic disease. The vision must deal with these issues.

We need a healthcare system which is seamlessly interconnected and coordinated. GPs and multidisciplinary teams are working under extreme pressure. We need targeted investment in primary healthcare to address this.

This investment can and will reduce the downstream cost. It will improve access to high quality GP-led primary healthcare services.

We know the statistics. Communities with access to more GPs live longer than those with access to fewer.

GP spending is approximately seven per cent of total health care expenditure from all levels of government. This equals about $382 per person per year. For comparison, $2606 is spent per person per year on hospitals.

Eighty-eight per cent of Australians will see a GP each year. Ninety per cent of healthcare problems seen in general practice are managed in general practice.

The Government has asked us to help develop a 10-year plan for primary health care and general practice. We are advocating for a system with patients and their care at the centre.

We have been advocating for a stronger Government focus on primary care – with leadership and coordination by GPs.

Primary health care is indeed the most effective part of the health system.

It is the engine room of the health system.

The strength of the Australian health system lies with the accessibility, efficiency, and cost-effectiveness of the primary care sector.

Primary care services are delivered in a range of settings - general practices, community health centres, aboriginal community-controlled health centres, allied health practices, and community pharmacies.

Primary health care is usually the first point of contact for all Australians for health care.

General practice is the cornerstone of, and is pivotal to, successful primary health care. Through high quality general practice, we achieve the best health outcomes over time.

General practice has been described as the “central discipline of medicine around which medical and allied health disciplines are arranged to form a cooperative team for the benefit of the individual, the family, and the community”.

General practice and allied health providers together form a patient’s healthcare team.

We work in partnership to ensure patient access to comprehensive and holistic care and better outcomes.

Team-based care is integral to high quality primary services.

It is a model of care we must embrace and strengthen if we are to continue to provide high quality care and the best health care outcomes in the world.

The primary healthcare system has four main purposes:

  • to provide the right care at the right time, at the right place, ensuring a healthier population;
  • to provide cost-effective, community-based care, and minimise hospital-based care;
  • to act as both an enabler and gateway to other services to ensure they are provided in a timely way, but only when needed; and
  • to coordinate care between different health providers and different parts of the health care system, ensuring a seamless, integrated, effective experience for the patient - and minimising costly fragmentation, duplication, or gaps in care.

Our role as a health care team is ensure that we can provide our patients with affordable, timely, appropriate and seamless care, which supports them in living a productive and quality life.

Primary health care is evolving to meet the challenges of a population that is living longer.

They will require the breadth of our services to keep them active and managing the conditions that come with age.

As already stated, the number of Australians experiencing a chronic condition is rising, and those with one or more chronic conditions often have complex health needs.

Addressing these needs will involve the health care team working collaboratively, within the scope of their practice, to provide flexible and person-centred treatment models.

But it is not just about treating chronic conditions.

We also work collaboratively, and will need to do more so on preventative care and rehabilitative care.

Many of the services provided by allied health providers contribute to improving people’s health literacy, healthy and active living, mobility, recovery from trauma, and general wellbeing.

For decades, general practices have been employing nurses to assist GPs with the provision of care.

Increasingly, general practices are also bringing in-house the services of diabetic educators, exercise physiologists, podiatrists, psychologists, physiotherapist, dieticians, non-dispensing pharmacists, and so on.

This is not new. What is new is the expansion and coordination of the services they provide to best meet the needs of their patients and the community.

They are building a medical home for the provision of patient-centred care.

Like GPs, though, most of your services are self-referred.

Our fundamentally autonomous operating models can and do occasionally lead to the fragmentation of care. This must be avoided.

It can result in us working at cross purposes, and not as effectively and efficiently for the patient as when we are working in tandem. With scarce health resources, we cannot allow this to continue.

Effective inter-professional communication is essential to ensuring the patient’s best interest and better patient outcomes. 

The chronic disease and mental health planning items under the MBS have seen GPs and allied health professionals increasingly working more closely.

The care planning and team-care arrangement items in the MBS have taken us forward with our inter-professional communication.

This was just the first step.

But there is more we need to do to ensure appropriate transfer of care and communication in relation to a patient’s care and progress.

Closing the feedback loop is vital.

The AMA has recently been involved in the Department of Veterans’ Health Allied Health Review, which reinforced the need for this with the introduction of the DVA Treatment Cycle.

It ensures that the GP is kept in the loop as to the impact and progress of a referred service in addressing the health needs of the patient.

Earlier this year, the AMA also provided input to the Australasian Integrative Medicine Association Interprofessional Communication Working Group on principles to guide the initiation of contact and follow-up between allied health provider and GP.

Working in collaboration with the Pharmaceutical Society of Australia, the AMA developed and advocated for its Pharmacist in General Practice Incentive Program.

This has been incorporated by the Government into the Practice Stream of the Workforce Incentive Program (WIP).

The WIP is expanding on the current Practice Nurse Incentive Program to support all eligible general practices from 1 January 2020 to engage the services of nurses, Aboriginal and Torres Strait Islander Health Workers and Health Practitioners, and allied health professionals, not just those in Urban Areas of Workforce Shortage.

The evidence shows that integrating pharmacists into general practice increases opportunity for communication and collaboration with GPs, improves medication management, and delivers better outcomes for patients.

This currently occurs in teaching hospital ward rounds.

The pharmacist is a valued member of the care team helping deliver improved outcomes. We want to see this in the community.

The AMA recognises the potential for the medical home model of primary care to enable well-coordinated multi-disciplinary care for patients, particularly for those with chronic and complex diseases.

Allied health providers working collaboratively with GPs is vital for providing comprehensive patient care.

Examples of this include:

  • identifying and managing Autism Spectrum Disorders and other neuro-developmental disorders;
  • supporting patients’ rehabilitation after a stroke or heart surgery;
  • for falls prevention;
  • helping patients with musculoskeletal conditions move more;
  • improving patients’ management of their diabetes with education and nutritional advice;
  • supporting patients with mental health conditions;
  • and supporting palliative patients and ageing patients.

As a team, we work collaboratively to improve patient health, functionality, wellbeing, and quality of life.

In practices operating under a medical home model, we see the in-house team of GPs and allied health professionals regularly collaborating on key patient issues, care objectives, and actions required across the team.

This ensures team members are on the same page when it comes to a patient’s care and are working together to deliver the right care and better outcomes.

So far, I have tried to emphasise concepts of particular collaboration and team-based models of patient-centred primary care.

In a medical home model or team-based model of care, the patient-care responsibilities are shared among members of the team.

Let’s examine what this could look like. In one example, the practice nurse on a weekly basis will identify patients of the practice who are due for a preventive screen or follow-up appointment, and contact the patient to arrange a time for them to attend the practice or perhaps have a video consultation.

The nurse might also check on patients whose condition is being actively monitored – perhaps they have just come out of hospital, or are ‘ageing in place’ and have recently had a fall.

This could be done by a video conference, or the patient could be sharing biometric information via a health app, or directly from their smart swatch.

Readings outside the norm for that patient would be reported to their GP who would advise what action is required.

It might be the in-house pharmacist having a chat to see if the patient is taking medication as prescribed or may have taken something that is contraindicated – it might require the patient to be called in for a physical assessment.

The pharmacist would be conducting a medicines review for patients due to be discharged from hospital.

Patients attending the practice would be triaged by a nurse. For example, having their blood pressure, weight and waist measurement taken, and perhaps a question or two on their reason for attending (if a walk-in) or how they’re coping following a recent death in family.

All this information would then be provided to the GP in warm handover.

The GP can now spend the allotted time on clinically assessing the patient, or checking their progress against the management plan and discussing with them any proposed action.

The GP can check to see if the patient is hitting their goals within the plan. They can consult the dietician about weight, they can consult with the physio on lifestyle interventions, monitoring balance for falls prevention.

With the patient they can discuss any tests they’d like to run and why, or perhaps a referral they’d like to make to additional allied health provider to assist the patient cement the progress they have made on recent lifestyle changes.

The medical home model of care aligns with Bodenheimer’s Quadruple Aim in that patients, providers, the health system, and population health all benefit.

There is strong evidence to support the positive benefits of the medical home model of primary care:

  • Improved access to care.
  • Improved clinical parameters and outcomes.
  • Improved chronic and complex disease management.
  • Improved preventative care services (e.g. Vaccination, health checks).
  • Improved condition-specific quality of care.
  • Improved palliative care.
  • Decreased use of inappropriate medications.
  • Reduced avoidable hospital admissions and readmissions, emergency department use, and overall care cost.

The biggest challenges I see with making this type of practice the norm is making the cultural change required, modifying existing workflows and payment models, using technology to streamline communication, and safely enhancing patient access to care - and funding it.

Technology, data, communication, access and funding.

Funding it in a way that supports change.

Funding it in way that recognises and remunerates the contribution of team members.

Funding it in a way that supports patient care outside of a face to face attendance.

Funding it in a way that is flexible enough to enable the customisation of services to the specific needs of the medical centre, its patients, and the community.

Funding it in a way that values outcomes over volume.

Fee-for-service may work in some instances, but not all.

Incentives may support change and improvements in care, but if devalued over time through inadequate indexation or hampered by arbitrary caps on practices, then they will not be sustainable.

Overarching payments that are stratified for patient risk and complexity may support continuity of care and coordinated care.

Overall, a blended funding model and a plan to support reform are needed.

The AMA will be working with the Government to develop a long-term funding plan to better enable general practices to transform into patient-centred medical homes.

Enabling the provision of a comprehensive range of services, utilising the multi-disciplinary health care team to their full scope of practice.

Services that include preventative measures to reduce patients’ need for more complex, high-cost health care, particularly for patients with or at risk of chronic disease.

Enhanced access to allied health services, noting not all members of the health care team may operate in-house, must be well coordinated by the usual GP to ensure it aligns with patients’ health care objectives, and is cost effective.

The AMA wants to see a more robust funding model, which builds on existing fee-for-service arrangements, to enable patient to access improved care in the community.

As per the themes covered in the Allied Health Reference Group, we need to work together to:

  • Ensure that clinical services align with best-practice guidelines.
  • Increase access to allied health in primary care.
  • Ensure that the list of eligible allied health professionals under the MBS reflects contemporary practice.
  • Facilitate group-based allied health therapy where required.
  • Ensure that patients with Autism spectrum Disorder, Pervasive Developmental Disorder, Complex Neurodevelopmental Disorder, or disabilities have adequate access to high-quality allied health care in Australia.
  • Strengthen the evidence base for the provision of allied health care in Australia.
  • Improve access to allied health services in rural and remote areas.
  • Change the delivery model and focus of allied health in Australian primary health care.
  • Improve communication between allied health professionals and other health care professionals.

Primarily, we need to work together to connect care and not fragment it.

We need access to interoperable systems that facilitate secure communications, the transfer of relevant clinical information for referred or requested services, updating on progress against the management plan, and the transfer back of care.

We need to think about working together instead of by ourselves to access better infrastructure than a single provider structure might allow.

We might need to think about providing services from multiple locations – spreading the services needed across medical home practices and locations to ensure community access to the services needed. We start to look at the patient-centred medical neighbourhood.

This is particularly important in and across rural settings.

The AMA is always open to collaborating with allied health stakeholders on policy initiatives or projects that support these elements:

  • GP centrality to patient care.
  • Patient-centred care.
  • Continuity of care.
  • Accessibility of care.
  • Coordinated care.
  • Comprehensive and holistic care.
  • Accountable care – care that is appropriate, cost effective, and efficacious.

That sounds like a plan.

Thank you.