The importance of primary and community care

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The Australian primary health and community care system is inequitable, inefficient and there is only very limited information about its quality. Yet it is highly likely that demographic, technological, social and economic change will result in increased demand for these services. Notwithstanding the available evidence, to date attempts at reform have been piecemeal. There is an urgent need to develop a national strategy for primary health and community care.

Primary health and community care is the most visible and commonly used part of the health system. In 1999-00 the Commonwealth provided approximately $6 billion through the Commonwealth Medical Benefits and Pharmaceutical Benefits Schemes. States and Local Government provided approximately $1.8 billion for ‘community and public health’. The Commonwealth, through direct outlays ($ 6 million) and private health insurance premium rebates ($97 million), also provided $103 million for dental services, with the States and Territories contributing $305 million. This does not include the substantial funds committed to the various forms of community support for people with disabilities, chronic illness and mental illness.

Internationally there is increasing recognition of the importance of the primary care system for improving health outcomes and managing costs. Stronger primary health systems are associated with better health outcomes and lower costs, particularly for children. Improved primary health and community support also has the potential to prevent hospital admissions, particularly for ambulatory sensitive conditions. As well, better primary health and community support can also prevent inappropriate and unnecessary use of residential care services.

However, Australian system is only intermediate on both system and practice characteristics. Countries such as Denmark, Finland, The Netherlands, Spain and the United Kingdom were all seen as having stronger infrastructure.

Primary health and community care services face unique challenges. Over the past three decades primary health services have come under significant pressure to address a more complex and diverse range of community needs. Several important trends have contributed to these pressures.

  • Support for the social rights of people with mental illness, disabilities and chronic disease has seen the closure of congregate care facilities and the development of programs to support people at home and in the community.
  • Cost pressures and the introduction of new treatment and information technologies has also made it possible for people with more complex conditions to receive treatment that was previously only available in hospital, at home or in ambulatory settings.
  • A greater appreciation of the social context for health has seen the development of services that address indigenous health, women’s health, cultural and linguistic diversity and consumer participation. Health promotion focused on social, economic, organisational and behavioural determinants of health has emerged a significant new area of activity for primary care services.

In response, there has been a very significant expansion of primary and community based services. Initially, new community programs and services emerged in disability services, mental health, aged care, drug and alcohol, and acute health. More recently, there has been a significant expansion of same day procedures, hospital in the home, rehabilitation in the home and community based care for people with chronic disabilities. Rapid expansion has lead to problems with equity, efficiency and quality.

Equity
The introduction of Medicare ensured reasonably equitable access to primary medical services, but significant problems have now emerged. Increasingly, a mal distribution of general practitioners has reduced access to primary medical services in rural and metropolitan fringe settings and long waiting times for routine appointments are now being reported in some areas. Over the past eight years, the incidence and magnitude of co-payments has increased with the likely effect of disproportionately reducing access to primary medical services for people on lower incomes. In response, recent changes to the structure of Medicare which incentives to bulk bill people on low incomes and children under 16 are likely to produce a two tier Medicare system.

The Pharmaceutical Benefits Scheme (PBS) has also ensured reasonably equitable access to a national formulary. However, recent proposed increases to co-payments in response to concerns about rapidly increasing costs associated with the introduction of new products on the PBS are likely to have an inequitable effect on access for people on lower incomes who are ineligible for concessional access to the scheme if they are introduced.

Notwithstanding emerging issues, access to general practice and pharmaceuticals is much more equitable than for other primary care services. Access and utilisation for dental, allied health and counselling services vary significantly with location and income. Those with higher incomes who live in metropolitan are more likely to use private providers for these services. For those on lower incomes, publicly provided services are budget capped and rationed. In Victoria for example, it is common for people on low incomes to wait a month or more to get an appointment for publicly funded allied health services and much longer for routine public dental treatment. With the effective abolition of the community health program during mid 1980s, there has been no national framework to address these issues for nearly two decades. As a result service mix and eligibility criteria vary across jurisdictions.

Access to community based continuing care services varies significantly across people with very similar needs, depending on historical evolution of programs and eligibility criteria. For example, while the Home and Community Care Program has very dramatically expanded community support for older people with disabilities, comprehensive national programs for other groups with continuing care needs have not developed. As a result, people with mental illness, chronic disease, post acute care needs, alcohol and drug problems and younger people with physical and intellectual disabilities have much more variable access to publicly funded primary health and community care services across jurisdictions.

Efficiency
Empirical evidence on technical efficiency for primary care and community support is scarce. Unlike acute and residential care, there is no national framework of output or outcome performance measurement for primary health and community care services. State based funding allocations are often historical and payment schemes are largely reimbursement or block grant based with little information on comparative costs or performance.

Nor is there much data on referral patterns and linkages between services. But even a cursory analysis of the organisational, payment and accountability arrangements suggests that transaction costs are high. With the exception of general practice, there are few systematic, national incentives to drive organisational and practice innovation. Governments exacerbate this problem by having different payment, performance reporting and accountability requirements for similar services and target populations.

Governance, organisational, payment and accountability arrangements do not currently promote integration and continuity of services for individuals or population groups with specific needs across agencies and providers (e.g. people with chronic illness, post acute care needs, alcohol and drug problems, people with disabilities, people with mental health needs, frail older people). Local responsibility for population health and the coordination of services and costs for specific populations is usually diffuse and fragmented. In this context it is not surprisingly that local health promotion, prevention and early intervention remain relatively under developed. There are also significant concerns about the continuity of care for individuals over time and across service types and sectors, particularly between acute, sub acute and community service provision.

Quality
Nor is there a consistent and comprehensive approach to improving and monitoring the quality of primary health and community care. The Quality Improvement Council runs a national scheme that accredits over three hundred primary health and community support agencies (http://www.qic.org.au/) and there is now a national approach to GP accreditation (http://www.agpal.com).

However, in general, there has been a proliferation of standard models for primary health and community care service often with variations across jurisdictions. There is little information on the safety of primary health and community support services, nor do we have information on consumer outcomes or consumer experience. At least one study of this issue with primary care physicians in the United States indicates this may be a significant issue.
At the same time there is a proliferation of standards and approaches to monitoring quality across jurisdictions and sectors.

Directions for reform
There is clearly a need to reconsider the development of a national policy for primary health and community support services. Such a policy might include the following elements to address the issues which have been discussed above:

  • National primary health and community care goals and objectives. For example, these might broadly set out equity, efficiency and quality criteria for the Australian primary health and community support system.
  • National performance indicators. For example, these indicators could be used to report on and benchmark the quality, access, efficiency and utilisation of the primary health and community support system and its impact on acute, sub acute and residential care.
  • Population based planning, allocation and monitoring. For example, funding allocation models and system governance arrangements based on the health care needs of geographically defined residential populations (e.g. Divisions of General Practice, Area Health Authorities, Districts, Primary Care Partnerships) that promote continuity of care and service integration could be considered.
  • Coordinated service pathways for health issues and conditions. For example, consistent best practice models linking prevention, early intervention, primary care, acute care, rehabilitation and community support should be developed for all major chronic diseases, mental illness and alcohol and drug problems.
  • Payment systems. For example a program to develop integrated payment models and systems for primary and community support services could be established and linked to Commonwealth/State agreements (eg. AHCAS, HACC) and own purpose funding streams. This might include consideration of capitated, case based, and contract funding to replace or compliment existing arrangements for primary care services.
  • National workforce planning and analysis for primary health and community support services.
  • A national evaluation, research and development program in primary health and community support services.
  • National planning and priority setting processes for primary health and community care to ensure greater alignment of Commonwealth and State priorities.

Notwithstanding the need to strengthen overall system capacity, it is clear that there are significant opportunities to strengthen integration across primary health and community care services (horizontal integration) and between these services and the acute and residential care sector (vertical integration). In the first instance, innovation trials should focus on the alignment of Commonwealth funding for divisions of general practice and State/Territory primary health and community support funding to promote greater integration of primary care services in prevention and health promotion, the management of chronic illness and complex conditions, post discharge planning and the provision of after hours services.

For health promotion and illness prevention, general practice divisions and relevant state based organisations such as Primary Care Partnerships in Victoria or Area Health Authorities in New South Wales could elect to participate in pooling non volume related payments such as the Practice Incentives Program, divisional project funding and State health promotion funding to develop integrated local health promotion plans. These would require local agreement about roles and responsibilities, funding and payment arrangements, objectives, performance monitoring, accountability and governance structures. Initially, integrated health promotion plans along these lines might build on the work of the Joint Advisory Group on General Practice and Population Health.

Funds pooling might involve either historical or, preferably, population weighted (capitated) allocations adjusted for factors such as age, sex, socio-economic status and rurality. Commonwealth allocations could be aggregated as Health Program Grants with similar arrangements for State funds. Funds could be held by divisions or state based organisations with appropriate joint governance arrangements. Service agreements would then be negotiated with general practices and other primary health and community support agencies to implement the agreed integrated health promotion plan. The governing body would then have responsibility for monitoring performance on service agreements against the plan and providing reports to the Commonwealth and the States accordingly.

Similar organisational arrangements could be developed between divisions and State primary health and community support organisations and hospitals to improve the integration of services for people who have a chronic illness or need post acute care services. Integrated local plans could bring together funding for multidisciplinary care planning and case conferencing for general practitioners with funding for post acute and chronic care including the Home and Community Care program. Over time, as capacity and expertise increase, the funds pool under the control of participating local primary health and community support organisations could be broadened to include pharmaceuticals and medical benefits. Capitated allocations to individual general practices for these volume related activities could be based on Standardized Whole Patient Equivalents used by the HIC for the Practice Incentives Program. Alternatively, new forms of general practice enrolment could be trailed, particularly for people with chronic and complex conditions.

There is now emerging evidence that closer integration of clinical decision-making and purchasing for enrolled populations in primary care settings through funds pooling and local purchasing has the potential to increase innovation, reduce costs and improve outcomes. These principles are being explored or actively implemented in number of countries comparable to Australia, including the United Kingdom and New Zealand.

There are many issues that need to be taken into account in developing integrated primary health and community support in Australia. These include bifurcation of responsibilities between the Commonwealth and the States, contested values between the major political parties, professional conflicts about the control and provision of primary health and community support services, the rapidly changing social, technological, demographic and fiscal environment, and the under development of primary care. Nevertheless, it is clear that significant improvement to the Australian primary health and community support system is possible. A national framework, an innovation fund and trials to promote horizontal and vertical integration are important if the Australian primary health and community support system is not to fall further behind comparable countries.

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