Primary care is the care provided at the first point of contact between a consumer and a health care provider. Typically, this refers to health care that is accessed by consumers directly within their communities, such as general practice, pharmacy, physiotherapy and other allied health services.
Primary care, which places an emphasis on the multi-disciplinary, preventative and well-managed care of a patient, may not result in as many newspaper headlines as hospital emergency departments but there is good international evidence that it does more for the health of our community than even the best run and
most well-resourced hospital.
Professor Barbara Starfield from Johns Hopkins University has done extensive cross-national studies of how different countries spend their health dollars. Overall her research shows that countries that invest more into primary care have better
health outcomes, lower rates of all causes of mortality (including heart disease and cancer) for a lower overall cost than comparable countries that put resources into other areas of health care such as hospitals and specialist treatment.
While the details of these types of studies can be challenged – there are always issues of data compatibility between countries that make comparisons difficult – what should be taken away from this impressive body of research are the clear general
trends she has identified across multiple studies. These clearly demonstrate that independent of the wealth of the country, health determinants (such as smoking rates), and amount spent on health care, countries will do better by focussing more on
primary care.
Given that we have a choice about where and how we allocate our health resources, the smart choice is to put funding into the areas that deliver us the greatest benefit. The case for primary care seems clear.
What are the specific problems with the Australian health system that can be addressed through an increased focus on primary care?
First is the issue of the lack of planning and coordination of health care, both across and within different health care sectors, and a subsequent inadequate approach to the prevention and management of chronic disease. For example, people with chronic conditions in the early stages do not receive appropriate care in the community and so go on to develop more serious health problems which require hospitalisation. This makes no health, social or economic sense.
For many common conditions, such as diabetes, arthritis and respiratory diseases, we know what care needs to be provided to
keep people in optimum health. Yet instead of making this care easily accessible, we force people with these conditions to negotiate a maze of different administrative, funding and service delivery arrangements to receive the treatment they require. Of course the end result of this is that many people miss out on the best care for their condition – even when this care is
not complex or expensive to provide – and so end up requiring more expensive care when their condition deteriorates.
This is why over half a million Australians end up in hospital unnecessarily every year, according to research conducted by the Australian Institute of Health and Welfare. Most of these admissions could have been prevented through better management of chronic disease in the community.
Strengthening our primary care system would take pressure off our over-stretched hospitals, allowing them
to concentrate on caring for those who really need hospital treatment.
So how should this be done? In a previous paper for the Centre for Policy Development I argued for multidisciplinary primary care centres to be established to provide coordinated and preventive primary care. Labor’s pre-election policy included a proposal for GP Super Clinics, very similar to the model published by the CPD.
These clinics aim to deliver a range of primary health care services, including general practice and allied health, and will be supported with infrastructure funding from the Government. A key feature of the Super Clinics, highlighted in Labor’s pre-election policy platform, was that they will focus on delivering more integrated and coordinated care to patients. This should
assist in the prevention and early management of chronic disease and reduce unnecessary hospital admissions.
For example, under the current model of general practice, a GP seeing a patient presenting with the early symptoms of Type 2 diabetes has to either manage the complex issues involved with this condition on their own or refer the patient to other care providers (such as a dietician or a diabetes educator) with whom he or she has little contact. From the patient’s perspective, this can often involve making additional appointments and travelling to separate locations to see other care providers who do not
know the patient’s history or original presentation and who treat the patient in isolation from the other care being provided. The aim of a coordinated primary health care service is for patients to be able to receive the care they require from a range of different health professionals working as a team in the one location.
The locations for the first round of the GP Super Clinics have already been determined, with an emphasis on areas with current GP shortages and a low socio-economic status.
These clinics will address some of the problems inherent in our current health system and provide the community with better health care only if they achieve two things: they need to provide both new care and better care, compared to what is currently being delivered.
If they provide the same care as is being provided elsewhere (just in a different setting) or different (but not better) care, then we cannot expect them to result in improvements in health outcomes. They will simply be shifting demand from one
area of the health system to another.
Of course access to GP services is a problem for many communities but it is not the only problem. The context in which GP services are delivered is also important.
We have a GP workforce shortage – at least according to estimates based on the way GPs currently practise. This will not
change overnight and even recent increases in medical school intakes and GP training programs will not meet the community’s needs for health care under our current model.
A better approach is to change the way in which we use our GP workforce. We need to start supporting GPs to work more
closely with other health care providers as part of a multi-disciplinary team. Many services currently provided by GPs can be safely and appropriately provided by other health care providers. For example, practice nurses can administer vaccines, dress wounds, perform pap smears and undertake medication reviews. These services would be provided under the direction of a GP and in consultation with the patient. Practice nurses already provide some of these services in some settings in Australia
but only to a limited extent – partly because of our current health financing system and the way in which general practices are organised.
Other examples of potential collaboration between primary health care providers include pharmacists assisting medical practitioners with prescribing, counsellors and psychologists working with GPs to treat people with mental health problems and
physiotherapists providing manipulative treatment to people with minor injuries.
Increasing support for a team-based approach to primary care should be a major focus of any primary care policies. Using other
health care providers to support GPs is not about providing second rate care. In fact, care provided by multi-disciplinary teams can often be of a higher quality and can better meet consumers’ needs for increased access to services than care provided by a
single practitioner.
The proposed GP Super Clinics should support a multi-disciplinary approach to primary care through co-locating a number of practitioners in the one setting. Often the barriers to greater collaboration between health care providers are simply physical – they don’t work close to each other. Changes which enabled Medicare to fund services provided by a greater range of health care
providers could further support this approach.
Another positive of the Super Clinics is that they should promote a more preventive focus for primary health care. Currently, GPs have little incentive to provide preventive health services to their practice populations. Medicare is designed to support individual episodic care, rather than population-wide preventive health services. To maximise the benefits of Super Clinics they should be used as a centre for preventive health activities for their community, such as vaccination and screening programs.
Super Clinics also offer the potential to establish more efficient ways of sharing health and medical data. In our current
system, the duplication of data collection and entry wastes valuable resources, and results in a large number of medical errors. These clinics offer the potential to develop better ways of sharing relevant data between health professionals – with the
consent and involvement of consumers – to achieve better and more efficient health outcomes.
While the number of Super Clinics proposed by the Government is relatively small, they do offer the potential to move primary care towards a more consumer-focussed system that delivers high quality and coordinated care, prevents the development and
progression of chronic diseases and reduces inefficiency.
They represent a small – but significant – step along the path of primary care reform outlined by the CPD and by health groups. The way in which they are implemented and evaluated will be crucial to ensure that they promote a better approach to primary care and not simply more of the same. Potential dangers to their long-term success are the possibility that they are seen simply as addressing areas of GP workforce shortages in the current system, rather than as a different – and better – way of delivering primary health care for all – not just the disadvantaged.
CPD will be watching with interest as the Super Clinics are implemented around the country and will continue to research, publish and promote ideas for a better primary care system for Australia.
