Thanks Ian.

The CIS paper seems to equate 'prevention' with 'health promotion' as though the main role of the super clinics will be to run anti-smoking campaigns! The main gains through an increased investment in primary care is in chronic disease management and screening/immunisation programs, ie. primary and secondary prevention of chronic conditions. Although health promotion may be part of what they do, I don't think it was the main focus of our paper. I am critical of many health promotion campaigns - of course many of them could be done better but (like Ian says) we have had some spectacular successes as well, such as in the area of HIV/AIDS. And the fact that not all prevention strategies work perfectly is not an argument for maintaining our current system of patchy and badly coordinated primary care.

The Centre for Independent Study has strongly criticised Jennifer's research in their latest Policy Monograph by Jeremy Sammut, The False Promise of GP Superclinics, saying...rather than keeping people well and out of hospital, GP Super Clinics are highly likely to put more people in hospital by uncovering unmet need for secondary care and tertiary treatment. GP Super Clinics will add to the demand and cost pressures public hospitals already face...". Download the full Policy Monograph, The False Promise of GP Super Clinics

I strongly agree with the analysis of the Australian “health system” (more accurately described by futurist Peter Ellyard as the “illness industry” for it is illness focussed and certainly not systematic) and the need for reform. There must be a considered Primary Health Care Policy but within the context of an integrated Health Care Policy. Primary care is essential as the basis for a good health system but some vital things must change - the funding system, the focus on illness, the way the "system" is designed for the needs of the health professions rather than the patients, and the idea that hospitals are desirable rather than as monuments to the failure of the health system.

The proposal to develop Primary Health Care Centres, while admirable, does not go far enough.

In particular the role of prevention is poorly spelt out and unimaginative. We need to address patients at risk of chronic disease by addressing the lifestyle determinants of their health - smoking, nutrition, physical activity, substance misuse, depression, anxiety, stress and the like. This should be done by a multidisciplinary team including nutritionists/dietitians, exercise physiologists, and psychologists. Maybe in the future we may see lifestyle coaches added to the team. These should all be based in general practice to make them more accessible. A better model is that of Wellness Centres as outlined in http://www.aph.gov.au/house/committee/haa/healthfu... .

Great caution must be taken when putting health care providers on governance boards. They tend to act in accordance with their profession’s/organisation’s needs rather than the community’s. Health professionals have a tendency to turn planning towards the most complex cases and can lead to overservicing. There probably needs to be a lay governance board and a multidisciplinary “clinical governance board” advising management.

There should be shared electronic health records and also shared electronic care pathways that link with the hospital, NGO, and private health care providers patient management systems. Patients would have to sign up to a data sharing confidentiality statement which should include some form of description of the benefit of continuity of care and the provision for reduced access for particularly sensitive data. This will reduce potential for errors and duplicated servicing. Patients would be able to add to records (electronic transfer of home monitoring of blood glucose or blood pressure monitoring are assumed) but not to edit them. The care pathways would allow GPs to book into hospital outpatient appointment scheduling once agreed established clinical criteria are “achieved”.

There should be a single business model. The purpose of the health system should be to keep the population well (as distinct to treating them once they get unwell). To achieve this primary health care providers should be funded on some form of population based formula with some adjustment for demographic differences (notably age and ethnicity). A population of 100,000 is large enough for “swings and roundabouts” to apply. The funding given to the PHCC Board should include what we now know as MBS, PBS, radiology and pathology subsidies, Department of Veteran Affairs primary health care funding, and HACC funding as a minimum but it must not be kept in silos. The PHCC will have to buy pharmaceuticals from pharmacists, radiology from radiological companies etc. This is to allow trade-offs between various modalities of care. For example it may be more beneficial to provide a more expensive drug to get a quick resolution to a problem than a cheaper one that requires more visits to the PHCC. It will certainly be more cost effective to treat say depression with physical activity than antidepressants. In the longer term it will be far better to prevent illness by lifestyle interventions than letting patients develop chronic diseases and then treat them. Of course there will have to be safeguards to prevent deliberate underservicing just as we now have the HIC monitoring overservicing. No PHCC will be able to turn away high risk patients. As occurs in New Zealand, a percentage of funding (say 10%) could be withheld unless certain levels of preventive care (e.g. 95% childhood immunisation, or cervical screening) are achieved.

I have strong concerns about the proposed staffing levels, especially of GPs. Even at the highest level of 20 GPs for a population of 100,000 gives a GP to patient ratio of 1:5,000 – far below the current urban level of around 1:1200. The number of GPs to service 100,000 at those levels would be in excess of 70. Even at the lower limit of 15 GPs the PHCC is probably too large to be manageable (one of the corporate GP companies has determined that 6 GPs is the optimal number). A better configuration would be small chains of centres having 5-6 GPs and a complement of allied health professionals and nurses. With shared electronic health records the lesser used allied health professionals could be rostered across all the centres in the chain as could visiting medical (and other) specialists for outpatient services. A chain would allow a better geographic spread (hence improving access) and improved functionality. Better still in more rural settings more distinct local identities could be established – particularly for aboriginal services. Again the chain concept is included in my Wellness Centres paper.

We have a reasonable illness industry but the development of Primary Health Care Centres and/or Wellness Centres could bring us a health system for the 21st Century. We now need political and bureaucratic leadership.

I would suggest that Evan has taken a contrarian view on the basis of prejudice rather than principle.

On the subject of prevention, the paper quite clearly articulates the desire to deliver individuals not only continuity of care, but also advice and counsel, across their lives. It does this by recommending registration with a specific centre, and a unified patient-controlled database.

Further, it articulates the need to examine funding models which go beyond the current fee for service model, which plainly encourages throughput rather than stewardship.

The current GP-based system, and its funding arrangements, imposes substantial out-of-pocket costs and inconvenience for any services beyond the remit of the GP - it is hardly the basis for holistic health management.

The paper is the result of expert policy input - a loaded term - but that input includes major state-based community and stakeholder consultations. It is therefore hardly "a solution in search of a problem"; rather it is a distillation of obvious structural shortfalls into a cogent policy solution.

Are there improvements to be made, more practicable responses? I'm sure there are, and that constructive input would be appreciated.

Gavin Mooney, Professor of Health Economics, Curtin University

This paper [1] is very welcome. Primary health care (PHC) in Australia is important but currently is not delivering either efficiently or equitably. There needs to be radical reform and the ideas presented in this paper make an excellent start. We have increasing evidence in the international literature that PHC can not only produce good population health but also reduce health care spending. So it matters.

PHC in Australia is currently very much dominated by GPs. That might be OK if the GP sector were thriving but the dominance of fee-for-service medicine and the fact that primary care Medicare is a metropolitan system lead to inefficiency and inequity respectively.

There is a need for much more integration of PHC services as the paper brings out. ‘One stop’ PHC shops are surely the way to go and the GP Plus model [2] of South Australia (more below) looks very useful for both integration of services and for acting as a hub to help people through the maze of PHC services potentially available – if clients could but find them.

The emphasis in the paper on integration and coordination has to be right as that is the key issue facing PHC in Australia.

My comments are not so much on what is in the paper with which I very much agree but are around my desire to take things further.

The paper is called a new approach to primary care for Australia. That is excellent but the paper does not live up the title and is almost exclusively about primary health care. A broader base is needed. Interesting in this context is the development of what is called the GP Plus Health Care Strategy in South Australia [2]. This primary care initiative is exciting and involves, as the Minister John Hill has described it, ‘collaborations between multidisciplinary health care and support services to provide integrated and continuing care to contribute to improvements in the health of the population’. It is a great initiative that has come into existence as primary health care but can so easily result in these GP Plus centres becoming primary care centres helping to coordinate and refer clients to not just health services but other (non-health) services as well.

There is also a need to think through more what and whose values are to underpin primary care in future. Certainly my own experiences with Citizens’ Juries [3] suggest to me that the case for such community preference elicitation is surely strongest in primary care and the community rather than in the hospital sector. We need the informed citizen’s voice to drive the values in health care but especially in primary care.

The paper argues that Australia has a strong GP sector compared with other developed countries. I would disagree and would want comparisons made more broadly and not restricted to English speaking countries. The Danes for example have got it right – at least for them – and we need to look at what we can learn from them. And why look only at developed countries when Cuba can with far fewer resources do so well in primary care?

A plea too to recognise the potential role of NGOs in primary care. They too have to negotiate the maze and spend too much time currently doing so, leaving often too few of their resources for service delivery.

The paper is good on Aboriginal health but might have drawn more on the experience with Aboriginal Community Controlled Organisations (ACCHOs) which in many respects are existing examples of Jennifer Dogget’s primary health care centres. They are community controlled; they are not GP-centric; they are about primary care and not just primary health care. They are a good starting place for examining reform in the primary health care sector in Australia.

The paper is surprisingly quiet on GP Divisions. Currently many of them spend too large a proportion of their funds spent on keeping their doors open. They are too small and too poorly funded to attract good managers. They are very GP focused and not primary care orientated and simply and increasingly arms of federal government with little discretion locally.

Yet – and this is the key point - there is an abundance of energy in at least some Divisions to try to get the system working to provide good primary care. The system works against this however.

There is a powerful argument for building on to this paper a strong divisional sector. This need to have primary care divisions and they need to have much more autonomy than the current lot do. They also need much more money and each to be much bigger. Currently there are 119 divisions and they receive about $75 million a year from federal government. I would suggest initially reducing the number of divisions to about 40 which immediately means tripling each division’s income. More importantly I would want to give them all the monies for primary care and leave them each to decide, for example, how to pay staff, including GPs. Currently the dominance of fee-for-service is a blight on delivering anything other than fast services. Some capitation element, especially in rural areas, is needed if GP, PHC and primary care are to be more population focussed.

There need to be some bodies in primary care to stand up to the powerful hospitals. The paper draws attention to the overemphasis in Australia on hospitals but does not grapple with the need to have a power shift in health care from hospitals to primary care. Without that shift in power, little will change. These new primary care divisions might be the answer. It might also be useful to do as the Danes do and have a separate union for GPs (but maybe call it something other than, as in Denmark, the PLO!).

References

1. Dogget, J. A new approach to primary care for Australia
http://cpd.org.au/sites/cpd/files/u2/A__new_approa...

2. Department of Health (2007) GP Plus Health Care Strategy. Government of South Australia: Adelaide.

3. Citizens’ juries in health; please say Yes Minister. http://cpd.org.au/node/3689

I have serious concerns about "Solutions looking for problems". That isn't to say that sometimes they might be the most appropriate at the end of the day.

This paper from the very beginning felt like a hard sell of the proposal. I don't think that is sound basis for developing Policy, and the latter is what CPD is all about.

As an example, no one in their right mind would argue that we shouldn't increase measures of prevention, but to claim that as a benefit of a new multi disciplinary primary health service isn't valid.

The issues and potential alternatives approaches were not discussed, contrasted and compared. Although a quote was made to some underlying values, which I think is great to see, the paper didn't then use them as basis for its approach and findings. EG, cost was raised as a significant issue related to values of equity, fairness and access, but alternatives for charging, funding, etc, were not covered.

I could go on. But I think a couple of examples surfice.

Very dissappointing.

My experience with elderly parents needing hospitalisation for operations and accidents was totally surprising and infuriating.
In a nutshell " CARE" goes missing from Health Care.
Experiences include
1) Irresponsible discharges from acute/major operations resulting in return via emergency services back to intensive care (three operations/ three returns)
2) Broken hip operated-on, but geriatric doctor did not appear for two weeks, nor could he be tracked down in his surgery nor within the hospital proper. Family, next of kin, left totally in the dark as to condition.
3) Broken hip patient left to own devices for ablutions resulting in fall in bathroom and severe shoulder injury, unhealed 6 months later.

These octogenarians paid health insurance thoughout a healthy life of 60 adult years. Now when needing attention the service paid for is totally substandard. Peace of mind as a sales pitch is effective until you enter the system.

So Private Health Insurance may assist the system cost wise and process wise but is not worth the outlay in terms of services purchased.

Elsewhere I have mentioned that technical skills are lost within the Industry by promotions to Management. This is not efficient or effective Division of Labour.

Also I have notified Canberra of a new report from the USA on the Health Benfits of Volunteering.
www.nationalservice.gov/pdf/07_0506_hbr.pdf
This has particular relevence with Baby Boomer retirements.

Finally I support any approach to devolve public service delivery. Canberra can still pick up the tab.

My local community centre rings me each autumn to remind me to get my free flu inoculation.

At that time I also have a couple of other checks I should have. I otherwise I would never bother.
fluff