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National Primary Health Care Strategy

Country: 
Australia
Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
(13) 2009
Author(s): 
Haas, Marion
Health Policy Issues: 
System Organisation/ Integration, Funding / Pooling
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Abstract

The Australian Government has committed to the development of the country's first National Primary Health Care (PHC)Strategy. An External Reference Group has produced a Discussion Paper, intended to provide a broad framework and basic information on key issues for PHC. It proposes 10 elements which could underpin a future PHC Strategy. A snapshot of each element is used to ask what happens now, what this means for community, consumers, health professionals, where could changes be made?

Purpose of health policy or idea

The purpose of the Discussion Paper is to stimulate input and comment to assist in the development of the PHC Strategy. The Discussion Paper has been developed by an External Reference Group consisting of representatives of provider groups and including consumers. The development of the Strategy will require consideration of a wide range of issues including current planning, delivery, governance and financing of PHC services some of which cut across National, State and Territory responsibilities. It is recognised that some aspects of the current system work well and these will need to be built on in the future directions and reforms which will make up the new Strategy. A draft Strategy is expected to be available for consideration by the Minister by mid-2009.

Main points

Main objectives

The Discussion Paper is one of a number of inputs to the development of a national PHC Strategy. The Strategy is one of a number of reforms proposed by the Australian goverment which are intended to deal with challenges identified as

  1. a growing burden of chronic disease, 
  2. an ageing population and 
  3. health workforce pressures.

At the same time, the complexity and volume of care required and delivered in the community is likely to continue to increase.

Type of incentives

At this stage, as the Strategy is not developed, no incentives have been identified. But, as the Strategy is explicitly intended to consider the financing and remuneration arrangements for the PHC workforce, such incentives can be expected to form part of the final Strategy.

Groups affected

PHC workforce, Patients, Government

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-dependent system-neutral

The ratings above which indicate that this policy is rather innovative, controversial and may result in fundamental changes to the Australian health system are predicated on the strategy including the most radical and far-reaching changes outlined as potentially available in the Discussion Paper.

There is no indication from the Minister which direction the strategy is likely to take and so these ratings may turn out to be the opposite of what actually happens. Although there was some media coverage of the release of the Discussion Paper, it was not widespread and there has been no follow-up coverage indicating any progress in the development of the strategy. The actual strategy may borrow heavily from other health systems (eg if a system for enrolling patients with their GP is adopted) but any transferability from Australia to otther systems seems unlikely.

Political and economic background

The National Labor government is committed to a raft of healthcare reforms. To this end, it has initiated a series of reform processes including a Health and Ageing Working Group, the National Health and Hospital Reform Commission (also see report Reforming the Australian Health System (13) 2009), a Preventive Taskforce and a review of Maternity Services. Thus, the development of a PHC Strategy is part of this reform process and is likely to inform and be informed by all of the other processes.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Origins of health policy idea

The Discussion Paper is one input to the development of the Strategy. A broad range of stakeholders is being encouraged to respond to the ideas developed in the Discussion Paper. Other inputs include research and expertise assembled from other sources.

Although the challenges have been recongnised previously, the responses have, so far, been incremental. The result is a PHC system that is characterised by an increasing proliferation of narrowly targeted programs and funding arrangements and growing inflexibility for healthcare organisations, professions and consumers.

There is increasing recognition of the need to improve integration between PHC services funded by the Commonwealth, State and Territory governments, aimed at reducing fragmentation of service delivery. The introduction of more flexible private health insurance (PHI) arrangements has also increased the scope for PHI providers to enagage with PHC to, for example, supplement the range of allied health services which are traditionally funded through PHI.

Initiators of idea/main actors

  • Government: The government has initiated the process and so is very supportive
  • Providers: Throught the External Reference Group, providers are being encouraged to have input to the development of the PHC Strategy
  • Patients, Consumers: Patients and consumers are being encouraged to also have input to the Discussion Paper

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

The Discussion Paper, developed by the External Reference Group, lists the following impacts on PHC which necessitate the proposed reforms:

  • changes in hospital services
  • increased focus on ageing at home
  • increase in care being provided to people in their homes eg dialysis, chemotherapy
  • increases in de-institutionalisation for mental health and disability
  • new technologies which can support community-based care
  • better knowledge and expectations at patient and provider levels

In the Discussion Paper, the challenges and future directions are grouped around four key themes: quality of care and health outcomes for consumers; health care service delivery arrangements; health workforce capacity issues; and fiscal sustainability.

While the Discussion Paper is likely to reflect the position of a number of stakeholders, further consultations will be undertaken.

Actors and positions

Description of actors and their positions
Government
Governmentvery supportivevery supportive strongly opposed
Providers
Providersvery supportivesupportive strongly opposed
Patients, Consumers
Patients, Consumersvery supportiveneutral strongly opposed

Influences in policy making and legislation

It is not known whether legislation will be required until the strategy is fully developed.

Actors and influence

Description of actors and their influence

Government
Governmentvery strongvery strong none
Providers
Providersvery strongstrong none
Patients, Consumers
Patients, Consumersvery strongneutral none
GovernmentProvidersPatients, Consumers

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The government (and, if legislation is required, the parliament) will be the main actors in the adoption of the strategy. However, much debate can be expected around the themes. The Discussion Paper has set out the challenges in terms of developing PHC services which

  1. are accessible, clinically and culturally appropriate, timely and affordable. Not all PHC services are equally accessible to all Australians. Funding is focussed on medical arrangements with recent extensions to a limted range of services provided by nurses and allied health professionals. This means that future reform will need to consider how to fund team-based models of care, substitution, where appropriate, of services provided by doctors with their provision by other suitably qualified providers, such as nurse practitioners.
  2. are patient-centred and supportive of health literacy, self-management and individual preference. This means that a future PHC system will need to be funded and organised to incentivise patient-centred care ie emphasise attention to patients' psychosocial needs, to facilitate patient involvement in decision making and promote effective self-care.
  3. are more focussed on preventive care, including support for healthy lifestyles. PHC tends to respond to problems already affecting the patient and the fee-for-service remuneration system for GPs reinforces this process. Although the professional bodies support the adoption of preventive strategies, a more systematic approach is needed. For example, the identification and measurement of risk factors and undertaking screening must be supprted by approriate financial and non-financial incentives.
  4. are well-integrated, coordinated and provide continuity of care, particularly for those with complex conditions. People with such conditions often need to see multiple providers and there is growing evidence that some degree of care management and coordination is necessary. With different levels of government funding different types of care (GP, specialist, allied health, hospital), the most approriate level for much coordination is likely to be at the PHC service level, particularly at the GP level. The recently introduced GP "Super Clinics" (also see report GP Super Clinics (11) 2009) are one means of addressing some of these issues. The Discussion Paper flags an enrolment scheme as a means of involving the GP in the coordination of the ongoing care of patients with complex needs.
  5. provide safe, high quality care which is continually improving through research and innovation. There is a lack of high quality research and evidence to inform the development of guidelines, protocols and pathways. In additon, there is little information allowing consumers to judge the quality of care provided by PHC services or the performance of PHC organisations. The Discussion Paper raises ideas such as incentives for PHC providers to collect data for monitoring purposes, making performance measurement more meaningful and making a clinical academic career more attractive.
  6. provide better management of health information, including the efficient use of e-Health. There is the potential for emerging electronic technologies to facilitate improved care. This requires both infrastructure and hardware as well as the approriate incentives to enable PHC providers to use all the technolgies available, including telehealth, electronic patient information forms and safety and quality tools.
  7. are flexible to respond to local needs and circumstances through sustainable operational models. PHC services are currently delivered by a range of types of services, including GPs and allied health professional (who operate as small businesses) and community health services staff (who are paid by States and Territories). More coordination between the different groups is needed for the planning and delivery of PHC services. The Discussion Paper indicated that a comprehensive model could include  the development of regional level organisations responsible for this work.
  8. provide working environments and conditions which attract, support and retain workforce. There are some workforce shortages in primary care, particularly in rural and remote areas of the country. The government has introduced some incentives to encourage PHC professionals to work in these areas and some excellent models of care (eg "hub-and-spoke", "walk in walk out") and e-health delivery systems are in place. All these initiatives need to be expanded and funded in a sustainable manner.
  9. provide high quality education and training arrangements. Limitations to training opportunities has a direct impact on workforce and therefore access to services. There is a need to achieve greater vertical integration of training opportunities and for education and training to be developed for multidisciplinary approaches to PHC delivery.
  10. are fiscally sustainable and efficient. The Discussion Paper recognises that the current financial arrangements including which services are subsidised are largely the result of historical arrangements rather than rigorous assessment and comprehensive design (although the evidence to support this is limited). There is a need to make explicit decisons about which cost-effective services in PHC should be funded directly by the government. There also needs to be some decisions made about the balance of resource allocation between PHC and other levels of service provison. Finally, how PHI arrangements fit into PHC service provision needs to be considered.

Monitoring and evaluation

Once a draft strategy has been developed, there will be an opportunity to evaluate its potential impacts on the challenges identifed above. For example, proposals to develop multidisciplinary teams will need to be evaluated in terms of the options for funding and remuneration mechanisms, the availability of workforce and the need for additional education and training.

Results of evaluation

not applicable

Expected outcome

A draft PHC Strategy is expected to be delivered to the Minister for Health by the middle of 2009. At that time, further consultations would be expected to take place, including with the Extended Reference Group who developed the Discussion Paper. It is likely that some proposed inclusions in the Strategy will not be contentious, but any proposals to change funding and remuneration arrangements are likely to be debated by the professions; at the same time any proposals which cross organisational boundaries (ie between the Commonwealth and States/Territories) are also likely to be contentious.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low high very high

It is unlikely that a new high level strategy will have a major impact on the quality of care overall, although it may have an impact on the quality of care provided to sub-groups within the population eg those with complex needs or people living in rural and remote areas of the country.

However, if a radical strategy is adopted, including changes to the funding, remuneration, organisational and delivery arrangements for PHC services, it is likely that the system will be more equitable and more effiicient.

References

Sources of Information

The Australian Government. Towards a National Primary Health Care Strategy. A Discussion Paper. Department of Health and Ageing. Commonwealth of Australia 2008.

Author/s and/or contributors to this survey

Haas, Marion

Suggested citation for this online article

Haas, Marion. "National Primary Health Care Strategy". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/au/a13/4