A better, GP-centred, primary healthcare structure

Posted 12 March 2015

On 10th March 2015, the Senate Select Committee on Health has organised a public hearing, where a presenataion has been given by Professor Mark Harris, the Executive Director of CPHCE, and Dr Michael Moore, CEO of Inner West Sydney Medicare Local.  A summary of the presentation has been published as below for your interest.

A better, GP-centred, primary healthcare structure

International research shows that a strong primary health care system is associated with improved population health, decreased health costs, appropriate care and positive health outcomes. An under resourced, poorly performing primary care sector adds a significant burden on the more expensive secondary and tertiary care sectors.


The case for change in Australia’s primary care sector

There is:

  • A growing burden of chronic disease
  • Poor integration of care
  • A maldistribution of providers
  • Disparities in access to care
  • Suboptimal quality and safety of care


What needs to happen.

Australians need:

  • Better, more organised disease prevention
  • Better management of chronic disease
  • Improved access, and improved handover between services
  • Reduced inequity
  • Improved quality and safety


Better, more organised disease prevention

Diabetes: an example: About 1.1 million Australians currently have diagnosed diabetes

More than 2 million Australians have pre-diabetes, with effective prevention strategies in place, 58% of these people if detected and appropriately managed would be prevented from progressing to frank diabetes. Amongst other things, diabetes doubles the risk of dying from cardiovascular disease including stroke and causes renal disease, eye disease and predisposes to infection.


Dementia, arthritis, kidney disease and lung disease (amongst others) are also on the increase.


Australia does poorly at preventing cancer.  Australia has a better than 90% immunisation rate, yet pap smear take up is about 57%, breast screen 55% and bowel screening 40%.  Victoria’s cancer council has estimated between 1,000 and 1,500 lives are lost per year in Australia due to our sub optimal cancer screening.


Better management of chronic disease

GP software is not set up to easily manage chronic disease, and the general practice workforce is, in international terms, lacking in practice based nursing support. Practices that systematise team based care and employ practice nurses are better at chronic disease management and are much better at prevention. We should be doing far more as a nation to promote the uptake of team based care in Australian general practice. Web based Health Pathways that many health districts are starting to implement are also a step in the right direction, providing not only better access to secondary care but also greater consistency and continuity of care as patient move across our very complex and fragmented health care system..


The current system of financing care for people with or at risk of chronic disease is complex.  This is not only because of two levels of government involved but also because of the way services are funded.  There needs to be a shift away from the current fee for service system for people with long term conditions to one that funds their care across multiple service providers based on need and the performance of the services in providing high quality care.


Improved access to care

Services can be available and overstretched, available but unknown, or not available at all.  It can be a lottery as to whether or not your provider knows or doesn’t know about a particular service that you need. A long awaited solution for this is good quality, web based service directories, and in the internet age we are all working towards this.


But there is much to be done and much service data is still, surprisingly, either unavailable or even believe it or not, secret.  What are the names and addresses of all the allied health practitioners in Australia that can access the MBS?  Medicare knows, but can’t tell anyone because under the current Medicare legislation, that’s secret information.  Which organisations access Commonwealth funds to provide health and social services? We can’t tell you who they are and what they provide, not because it’s a secret, simply because there is actually no comprehensive database of who gets Commonwealth funding, and for what, that anyone can access.


It’s not just the Commonwealth that has issues with tracking who they fund and who they license, there is a similar paucity of publicly available data on available state funded services. And when it comes to the NGO level, and private services, there is almost nothing.


The national health service directory is a step in the right direction, (and before them Commonwealth CareLink also started to address this issue) but not withstanding that these are both Commonwealth initiatives, not even they have access to a lot of Commonwealth data, and they struggle to access state held data.  Our local HealthPathways site is looking at integrating NHSD data with their disease management pathways, but from working closely with them it is clear that there are challenges. 


It’s hard enough getting the phone number and access criteria for a service, getting their secure messaging ID is in most cases currently almost an impossibility (assuming that they have one!).


Reduced inequity

Geographical maldistribution of providers in Australia is well known.  Although Medicare went some way to equalising social access to medical services it hasn’t worked well for people in geographically isolated areas.  But geographical maldistribution is not the only kind of maldistribution. Within general practice, there is a cogent argument that Australia has an undersupply of nurses working in general practice.  People who attend practices that employ one or more nurses in a team based care arrangement are more likely to receive good prevention and more thorough chronic disease management. We should be doing far more to promote nurses in general practice


Improved quality and safety

General practice, pharmacy, physiotherapy and dentistry are the only primary care streams that have facility based accreditation.  The other 14 or so strands of allied health do not have any site based quality certification process.  Only general practice and pharmacy receive incentives for having their facility quality certified.  Unlike hospitals, there is no comprehensive incident and error monitoring process in primary care.


What can we do?

Here are some proposed solutions. Some of these solutions address more than one priority.  It’s not a comprehensive list, but it’s a starting point.


First of all, quoting Prof Horvath, there is a genuine need for an organisation to be charged with improving patient outcomes through working collaboratively with health professionals and services to integrate and facilitate a seamless patient experience.

  • increasing the efficiency and effectiveness of medical services for patients
  • improving coordination of care



National registers

Incentives for providers, and for people

An organised approach to cancer screening, like we had for immunisation

An organised approach to diabetes screening

Empanelment: linking every Australian to a responsible primary care provider

Packaging of funding for patients with chronic disease to allow more integrated service delivery


Chronic disease management

Better Information technology, Better software, Better electronic communication

Better systems, better integration

Directories of secondary care and social care

Health pathways

Patient centred care: Involvement of consumers and carers


Financing and performance

MBS item reform

– incentivise, and measure the change in behaviour

PIP reform

- PIP better placed to incentivise system change

- incentivise and measure the behaviour we want

- provide the PIP to more than general practice and pharmacy


Infrastructure reform

Practice nurse promotion

Data reform – privacy principles are there to protect consumers, not make it hard for consumers to find services and businesses