Primary HealthCare Reforms in Australia - Case Study Example

RUNNING HEAD: PRIMARY HEALTHCARE REFORMS Primary HealthCare Reforms [Name of the Writer] [Name of the Institution] Primary HealthCare Reforms Introduction The primary care sector In common with the UK, general practice is the first point of contact with the health care system in Australia and GPs act as gatekeepers to the specialist medical and hospital sectors. Each year over 80% of Australians visit a general practitioner (GP) and on average Australians have 5.5 contacts with or services from a GP annually (Commonwealth Department Health & Family Services 2006). Services are provided on a fee-for-service basis and rebates are provided through Medicare at 85% of the schedule fee, which is set by the government. However, most individual patients do not bear out of pocket costs for GP visits, as over 80% of GP services are bulk-billed; that is, doctors accept the government rebate as full payment. (Bradley & Field 2005, Smith & Taylor 2006) Since 1992 the Commonwealth government has invested in the General Practice Strategy which is designed to address the isolation of general practitioners and the escalating actual and flow-on costs of general practice (Commonwealth Department of Health & Family Services 2006). The improvements in primary care encompassed by the General Practice Strategy are therefore being sought in a climate of government commitment to restraining expenditure on health. The key structural change to general practice as a result of the strategy is the dedicated investment in divisions of general practice. Divisions are regional networks of GPs, formed with the aim of engaging in cooperative activities and projects to enhance their integration with the wider health care system and to improve health service delivery at the local level (Commonwealth Department of Health & Family Services 2006.) Between 1992 and 1997, the Divisions’ Project Grants Programme funded divisions to undertake projects with the broad aim of encouraging GPs to widen their scope of activities and examine new models of primary care delivery. (Milne & Oliver 2006) These models had a strong focus on integration, access, education and public health. Divisions do not control, fund or provide clinical services by GPs. The divisions programme is now moving to outcomes based fundings, whereby divisions receive fixed budgets proportional to the population in their area and funding is linked to agreed outcomes, which can be defined and measured. There will be a focus on the development of longer-term programmes of activity targeting local and national health priority areas, and there is an expectation that divisions should be able to demonstrate some logical progression towards population-based health outcomes. This funding change gives divisions far greater autonomy and flexibility in their choice of activities. Whilst these changes are at an early stage, they represent a significant development in linking divisions with local needs, priorities and services. They encourage divisions to promote quality in general practice, incorporate evidence into practice and to focus on outcomes as well as process. The changes are ambitious; both data collection systems and the necessary intellectual capital to focus the programme on population outcomes are at an early stage of development. The changes have, nevertheless, encouraged a dialogue about outcomes, evidence and Australian primary care. (Milne & Oliver 2006) The establishment of a divisional infrastructure provides therefore an important vehicle for the promotion of reform in Australian primary care. It also encourages general practice to participate more readily in reform programmes at regional and national level and to engage with other health care sectors. Challenges for the implementation of Reform in Australian primary care The nature of primary care In common with other countries with well-developed systems of primary care, consumers of Australian primary care rarely have single discrete problems multiple and ill-defined problems are the norm. Difficulties are therefore often faced in identifying a discrete problem for which a reform approach might be appropriate. Indeed, many argue that reform has the potential to detract from the generalist, person centered approach that is highly valued in primary care settings. Commentators on reform have described its uneasy relationship with the intuitive, narrative and interpretive aspects of primary care and the dangers of trying to reduce the complexity of primary care by focusing on single problems (Bradley & Field 2005, Smith & Taylor 2006). The challenge for reform in primary care is to affect change whilst remaining sympathetic to these important, if less measurable, aspects of primary care consultations. Other issues which have featured in the debate over reform in Australia include the applicability of results found in the literature to individual primary care encounters. By necessity, trials of health care interventions of relevance in primary care are conducted in populations with characteristics that differ from those which are present in primary care. The limited applicability of the results of such trials are particularly evident in areas such as illness prevention, where trial participants may be unrepresentative of the wider population and interventions are difficult to reproduce exactly. Although work on the applicability of results between different contexts has featured strongly in Australian research on reform (Glasziou & Irwig 2005), there is a widely expressed need for research which is based in primary care. The Structure of Primary Care There are four key structural barriers which present unique challenges for the implementation and uptake of reform in Australian primary care. Firstly, the concept of the multi-disciplinary primary care team is widely known but rarely implemented. Australian GPs are independent contractors (in common with their UK counterparts), but there is no dedicated funding for other primary care team members such as practice nurses and health visitors. Hence, whilst multi-disciplinary primary care is discussed enthusiastically in government reports (General Practice Strategy Review Group 2002), it is not supported by an appropriate infrastructure. Secondly, the fee-for-service system and the fee structure for Australian general practice reward high patient throughput, since GP income is maximized through brief consultations. This means that Australian GPs focus on time management in daily practice; and initiatives that place additional demands on their time are unlikely to succeed unless they are linked to new financial incentives. Thirdly, the lack of a system of patient registration means that patients can move freely between doctors. Whilst this is a feature of the Australian health care system that is prized by consumers and by many GPs, it is a barrier to a population health approach at the practice level. Finally, Australian general practice lacks a history of experimentation with alternative organizational systems, in contrast to the UK experience with GP fund holding. (Milne & Oliver 2006) Although there is recent interest in major reform in primary care, Australian general practice is a relative newcomer to this field. The Wider Primary Care Context The move towards reform in primary care in Australia and New Zealand has not been confined to general practice; other primary care professionals are actively embracing the concept of systematic reviews and other tools of the trade of reform (McArthur 1997). The nursing profession in Australia, in common with other disciplines, is grappling with some of the implementation issues of reform, such as how to apply evidence obtained in one setting to another. The profession has established the Joanna Briggs Centre for evidence-based nursing to create a database of international research evidence on a wide range of nursing issues. It aims, like the Cochrane Collaboration, to ensure widespread dissemination of findings to promote improved clinical efficiency and effectiveness. Australian nurses are aware that the UK benefits from a stronger policy framework in the area of nursing and programmes such as the Clinical Effectiveness Initiatives by the NHS Executive and the Royal College of Nursing appear likely to provide motivation and facilitation of evidence-based practice within the Australian nursing profession (Regan 2002). When discussing the utility of the reform approach, rural health practitioners point out the inherent differences between rural and metropolitan healthcare cultures (McCarthy & Hegney 2002). In Australia, rural GPs face greater time pressures than their urban colleagues and have fewer opportunities for participating in multi-disciplinary teams. However, in many cases the opportunities for inter-sectoral collaboration are enhanced in rural settings. Divisions of general practice are well placed to utilize these linkages and thereby promote a reform approach. Evidence-based health care and consumers of primary care services from the outset, consumers have played an active role in the movement towards reform in primary care. Drawing on the success of other groups, including the NHS Centre for Reviews and Dissemination, which have established strategies for promoting informed patient participation in clinical decision making (Entwistle et al . 2002a), the Australian health consumer movement has developed a close involvement with groups that promote reform , including the International Cochrane Collaboration. Australian primary health care consumers are gaining access to research based information (of variable quality) through the Internet and other sources. Consumers are also becoming articulate about some of the skill-related aspects of reform, such as critical appraisal of literature (Milne & Oliver 2006). The processes and outcomes of evidence-informed patient choice nevertheless remain poorly understood and should be carefully evaluated (Entwistle et al. 2002b). It is critical, though, that consumers remain at the forefront of reform developments and there are examples of this working in practice. Moves towards evidence-based practice and the increasing focus on clinical outcomes have promoted the development of programmes with a focus on accreditation and standards, such as the Australian Council of Healthcare Standards. These programmes share similarities with the King’s Fund Organizational Audit in the UK and provide structural opportunities for continuing consumer involvement (Vidall 2002). Strategies in Clinical Settings The impact of reform in clinical settings also depends on the way that information is presented to primary care practitioners. It cannot be assumed that the simple inclusion of the words evidence-based in strategies aimed at changing clinical behaviour will be effective. For example, work on GP prescribing suggests that an emphasis on lack of therapeutic effectiveness is less likely to change GPs’ behaviour than information about risk to individual patients (Butler et al. 2002). Rather than teaching all primary care practitioners literature searching and critical appraisal skills, there is a need for systems which allow rapid access to credible summaries of evidence. Furthermore, reliance on the passive diffusion of information to keep primary care practitioners’ knowledge up to date has little chance of success in an environment in which about two million articles on medical issues are published annually (Hanes & Donald 2002). This has prompted interest in both the development of rapid-access information sources and in educating GPs and other primary care practitioners about how to generate questions from clinical encounters, with realistic expectations over the length of time required to adequately provide information. A feasibility study of a clinical information service for GPs has produced encouraging results (Butler et al. 2002) and a multi-centre trial, involving Australia and the UK, has been established. Conclusion In contrast, many Australian initiatives in primary care have occurred in a relative policy vacuum. Whilst the Australian primary care health service reform agenda has included important developments such as the establishment of divisions (and their recent move to outcomes based funding) and the General Practice Evaluation Programme, there has been little guidance for these activities from a coherent primary care policy framework. Many Australian commentators believe such a framework would effectively link research and evaluation to policy and thereby assist the implementation of reform in Australia. References Bradley F. & Field J. (2005) Healthcare medicine. Lancet 346, 838-839. Butler C.C. et al. (2002) Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. British Commonwealth Department Health and Family Services (2006) General Practice in Australia: 2006. Australian Government Publishing Service, Canberra. Entwistle V.A. et al. (2002a) Developing information materials to present the findings of technology assessments to consumers. The experience of the NHS Centre for Reviews and Dissemination. International Journal of Technology Assessment Health Care 14, 47-70. Entwistle V.A. et al. (2002b) Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies. International Journal of Technology Assessment Health Care 14, 212-225. General Practice Strategy Review Group (2002) General Practice: Changing the Future through Partnerships. Commonwealth Department Health & Family Services, Australia. Glasziou P.P. & Irwig L.M. (2005) An evidence-based approach to individualizing treatment. British Medical Journal 311, 1356-1359. Haines A. & Donald A. (2002) Making better use of research findings. British Medical Journal 317, 72-75. McArthur J. (1997) The systematic review: an essential element of an evidence based approach to nursing. Nursing Practice of New Zealand 12 McCarthy A. & Hegney D. (2002) Primary healthcare and rural nursing: a literature review. Australian Journal of Rural Health 6, 96-99. Medical Journal 317, 637-642. Milne R. & Oliver S. (2006) Evidence-based consumer health information: developing teaching in critical appraisal skills. International Journal of Quality Health Care 8, 439-445. Regan J.A. (2002) Will current clinical effectiveness initiatives encourage and facilitate practitioners to use primary care practice for the benefit of their clients? Journal of Clinical Nursing 7, 244-250. Smith B.H. & Taylor R.J. (2006) Medicine- a healing or a dying art? British Journal of General Practitioners 46, 249. Vidall S.A. (2002) King’s Fund Organisational Audit: more than ticks in boxes. Journal of Quality in Clinical Practice 18, 83-88, 10-15. Read More