Primary Care Reform in Australia:
general practice leading the way
Professor Claire Jackson
RACGP President
Professor of General Practice and Primary Health Care and Head of
Discipline, University of Qld School of Medicine
Australian healthcare system
(a snapshot !)
• Medicare: universal health insurance (1.5% taxable income)
• Strong public / private mix
• High international benchmarks in longevity, chronic disease
outcomes, survival rates, access, satisfaction, cost
• ‘Closing the gap’ – our national disgrace
• Dual state and Commonwealth funding arrangements, their gaps,
inefficiency and duplication a strong current reform focus
Australian primary healthcare:
context
• General practice ( our PCMH!)
o 27,000 GPs (predominantly FFS, SIP, PIP)
o Over 125 million consultations / yr, 80% ‘bulkbilled’
o see 83% population annually, big practices
o holistic, ‘cradle to grave’ model, team focus
• Community health (state-funded)
• NGOs – predominantly aged care
• Aboriginal community-controlled health services
Australian primary healthcare:
key national players
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Royal Australian College of General Practitioners
Australian Medical Association
Rural Doctors Association Australia
Australian General Practice Network, representing 100 divisions of
GP nationally
• General Practice Registrars Australia
• Royal College of Nursing, Australian Nursing Federation
• Pharmacy Guild
Australian primary healthcare
– what does the future hold ?
 2010
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National Health and Hospitals Reform Commission report
Australia’s First National Primary Care Strategy
GP Superclinic roll out (34 settings)
Legislation re personally controlled e-health records
MBS / PBS access for nurse practitioners and midwives
PM’s ‘Big Bang’: ‘National Health and Hospitals Network for
Australia’s future’ (1 and 2, COAG, 2010 Budget)
A major national health care reform agenda strongly focussed on primary care
The National Health and
Hospital Reform Commission
 Embed prevention and early intervention into every aspect of our health
system and our lives, particularly for children and young people
 Connect and integrate health and aged care services for people over
the course of their lives
 Strengthen primary healthcare services ... building on the vital role of
general practice...creating a platform for comprehensive care bringing
together health promotion, early detection and intervention, and
management of acute / chronic conditions
 Integrating multidisciplinary primary healthcare services with
Commonwealth oversight
 Establishing comprehensive primary healthcare centres and services
 Voluntary enrolment with a ‘healthcare home’
The National Health and
Hospital Reform Commission
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Expand specialist services / palliative care support / hospitals in the
community
Establishing PHC Organisations to support population health care planning
and coordination
Create a comprehensive primary healthcare platform under Medicare
(including state-health services)
Mix of funding models
Reshaping the Medicare Benefits Schedule (MBS) to reflect scope of
services to be included, competency and scope of practice, driven by
evidence and ‘continuity and integration of care through collaborative team
model of care
Fostering clinical leadership and governance and e-health
New framework for flexible, competency-based IPE and dedicated $ for
clinical placements and NCETA
Australian primary healthcare
– what does the future hold ?
2011
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Council Of Australian Governments (COAG) national health reform
heads of agreement
Creation of Local Hospital Networks (LHNs) as direct recipients of
Commonwealth and state funds
Strong performance accountability, measurement and public
reporting
Medicare Locals (MLs): primary healthcare organisations
responsible for coordinating and better integrating PHC services in
their local region, improving access, preventive health and
addressing care gaps (60)
Strong articulation between MLs and LHNs
Ongoing increase in GP training places, rural only increase for other
specialties
So, what does the future hold?
A major national healthcare reform
agenda strongly focussed on primary
healthcare
Key drivers
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Chronic disease prevention and effective management
Disaster fears (tsunamis, floods, fires)
Cost containment and ‘efficient costs’
Building quality
Improved access especially for marginal groups
International approaches
Public pressure
Where does primary care fit
into the Brave New World ?
• FRONT AND CENTRE
Limited only by its clarity of
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purpose
planning
imagination
infrastructure
The primary healthcare reform
environment
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Building a system from a sector
Increasing relevance, funding and accountability
Changing dual system governance structure
Improving integration with acute and aged care
Building effective teamwork across disciplines
Advanced and enhanced care opportunities within the
community
• Focus on regional integration of care, e-health, workforce
growth, infrastructure, and financing and system performance
GP Superclinics (2008-11)
• GP Superclinic: a comprehensive set of primary care services
led by a GP within an academic infrastructure
• Mixed reaction from the profession
• Key to the future is the specialist service enabler, breadth of
service and efficiency
• New initiatives include infrastructure support for conventional
general practice to achieve this
What is the focus for our sector?
• Building workforce, infrastructure, practice teams, training and
networks to deliver the futuristic healthcare service our
country is seeking
• Looking at how our holistic model of care fits with the future,
scoping opportunities and threats and moving forward with
high quality, comprehensive primary care
• Training – registrars, general practitioners with a special
interest (GPwSI) – building capacity to deliver efficient,
accessible, comprehensive community care
• Effective integration of a multitude of providers, services and
organisations under the Primary Healthcare
Organisations/Medicare Locals
Watch this space !
• A lot is happening Down Under which offers opportunities for
international collaboration and policy development
• Significant need for high quality research to inform the new
arrangements
• Concerns re governments’ track record in delivering such large scale
reform and small budgets from Medicare Locals
• But … first ever serious focus on funding, organisation and
accountability around integrated care delivery
• Recognition than improving primary care capacity and access a life
line to retaining high quality, affordable healthcare in our country
Some new models:
UQ’s Primary Care Amplification Model (PCAM)
Pilot: Inala Primary Care
• Creates a ‘beacon’ practice in an area which acts to support and
extend the capacity of primary care in the area, and better integrate
service delivery locally between general practice, specialist services
and other state-funded care
• Accomplished via the establishment of a general practice ‘mustering
point’ for an expanded scope of practice for primary care in areas of
population need, service innovation, teaching, ( u/g and p/g) and
relevant local clinical research.
UQ’s Primary Care Amplification Model (PCAM)
• Central to PCAM is the provision of the core elements of general
practice and primary care – first contact, continuous, comprehensive
and coordinated care provided to populations undifferentiated by
gender, disease, or organ system
• The Amplification Model features four additional key characteristics:
– an ethos of supporting primary care within and external to the
practice
– an expanded clinical model of care;
– a governance approach that meets the specific needs of the
community it serves
– and a technical and physical infrastructure to deliver the
expanded scope of practice.
• It is these characteristics that enable a ‘beacon’ practice to realise its
potential
The Primary Care Amplification Model
Ethos
• Physical infrastructure to support local practices increase their scope
of practice
• Undergraduate and postgraduate teaching
• Focus on supporting local practices in increasing the scope of
primary care delivery
• Advanced skill development
• Clinically relevant research/audit activity
• Culture of Continuous Quality Improvement
The Primary Care Amplification Model
Clinical Model of Care
• Well-integrated primary/secondary and multi-disciplinary team care
onsite
• Integrated clinical share-care protocols outside the practice
• Comprehensive chronic disease management with a strong patient
focus on site
• Preventative care
• After-hours provision for patients
• Electronic clinical information sharing
The Primary Care Amplification Model
Governance
• Integrated inter-organisational governance arrangements
• Commitment to local service innovation
• Provisioned planning ‘down-time’
The Primary Care Amplification Model
Infrastructure
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Comprehensive infrastructure within a single location
MBS Billing
Focus on access and affordability for local population
Local population health focus
The Primary Care Amplification Model
Outcomes
• Has made a difference to local patients / community / statefunded health care by building the capacity of primary care
around it to deliver expanded services – in the first instance in the
area of Complex Diabetes Management
• The AAAGP endorsed Superclinic model and prototype for the 3
UQ GP Superclinics
• IPC awarded RACGP Qld Practice of the Year (2009) and has
the support of local general practices and DGP in piloting this
new and evolving role in the primary care landscape
The Primary Care Amplification Model
Complex Diabetes Service
Subjects
Patients from surrounding 21 postcodes referred to Princess Alexandra
Hospital Dept of Diabetes and Endocrinology and whose GPs consent
to care via the new model
Location
Managed at Inala Primary Care
The Primary Care Amplification Model
Complex Diabetes Service
Intervention
DE Case manager screens patients and arranges appropriate Clinic Day
review according to need – eg podiatry, diabetes educator, doctor (all). Retinal
screening
On Clinic morning, patients reviewed by the “Clinical Fellow”, an advancedskilled GP trained via the UQ DGP’s online MMed (GP), who co-consults with
the specialist Endocrinologist and the patient to develop a management
approach
Case manager follows up patient with phone contact as appropriate to support
their participation in the management plan and self management program
Variety of education opportunities for local GPs via IPC and for Qld GPs via
collaboration with a number of Divisions of General Practice via CHIC
What patients are we dealing with?
ICDMS (n=169)
Age (yr) mean
61.3 ± 12.8
Female (%)
50.3%
ATSIC
5.4%
Born in Australia
47%
Education ≥ Yr 12
36.7%
BMI (kg/m2) mean
33.3 ± 7.8
Mean duration of DM
14 years
microalbuminuria
50%
Stage III kidney disease
25%
Nerve damage
32.5%
At risk foot
45.4%
Eye disease
20%
IHDx
29.6%
On insulin
49.7%
Glycaemic control for newly referred patients with T2DM at baseline and 12
months at the Brisbane South Complex Diabetes Service (BSCDS)(n=99) and
Princess Alexandra Hospital (PAH)(n=67).
Baseline
12 months
BSCDS
PAH
BSCDS
PAH
HbA1c (mean ± SD)
9.0±2.0
8.3±1.9
7.6±1.7
8.1±1.8
% achieving HbA1c ≤
7%
14.1 (14)
28.4 (19)
45.5 (45)
32.8 (22)
12 Month Data – Intervention Group
Paired t test baseline
vs 12 months
p value
Baseline (n=97)
6 months
(n=97)
12 months (n=97)
HbA1c (%)
8.4 ± 1.7
7.4 ± 1.5
7.7 ± 1.6
0.0001
Weight (kg)
91.3 ± 27.7
92.1 ± 24.9
95.7 ± 30.6
0.0001
BP-sys (mmHg)
130 ± 15.6
130 ± 13.5
128 ± 16.4
BP-dia (mmHg)
72.8 ± 10.6
69 ± 9.4
68.8 ± 11.1
0.003
Chol (mmol/l)
4.2 ± 0.9
3.7 ± 0.8
3.7 ± 0.87
0.0001
LDL (mmol/l)
2.3 ± 0.8
1.9 ± 06
1.9 ± 0.8
0.0001
early data suggests the benefits are sustained at 12 months
Why does it work ? Take from ‘The Big Losers’
The Service
Accessible, welcoming, team-based
The Team
The relationship of the team members with patients enabled: Patients'
to feel that the team really understood their problems, That they could
"talk openly about even little issues" with team members, Patients
treated as a person and not a number, Patients felt
comfortable returning for appointments, and once referred back to their
GPs could also contact the service if they needed additional input or
advice.
Most importantly, patients liked seeing the same team members
Why does it work ? Take from ‘The Big Losers’
Implications
The team improved patients' knowledge and understanding of type 2
diabetes, moved some patients from denial to accepting they had
diabetes - - - significant to engage patients in their own health
care. Team builds patients' confidence to effectively manage diabetes
in an on-going
The future is not a result of choices
among alternative paths offered by
the present, but a place that is
created – created first in the mind and
will, created next in activity.
The future is not some place we are
going to, but one we are creating.
The paths are not to be found, but
made, and the activity of making
them, changes both the maker and
the destination ‘
John Schaar, futurist