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Strengthening Primary Care in Australia: Challenges and Opportunities for System Reform

Suzanne Robinson Associate Professor and Director of Health Policy and Management at Curtin University

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Associate Professor Suzanne Robinson

Director of the Health Policy and Management and Health Information Management at the School of Public Health, Curtin University

WA Health Systems policy and Research Network

Research interests include health policy and systems research, economic evaluation

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Outline of presentation

Australia health system performance – national and international

Health system reform – The role of Primary care

The MCL vision

The MCL reality

The MCL possibility

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The Facts: Australia at a glance

23 April 2013: 23

million people

WA 2.45 million 2012

annual increase of 3.4 per cent

Average life expectancy male 79 yrs female 84 yrs

Average LE Indigenous pop male 59.4, female 64.8

64% of people live in capital cities15% of indigenous live in remote areas and 49% in very remote areas.

Unemployment Rate in Australia increased to 5.60% 2013

Australia was around 12t- 14h wealthiest among OECD countries

Australia top 20 most expensive citesSydney 7th

Melbourne 8th

Perth 13th

In 30 yrs the proportion of the population over 65 yr will almost double to around 25 per cent.

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A Typical Day in Australia

Source: BEACH (Bettering the Evaluation and Care of Health) Survey

Patient Complexities

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Australia health system performance

Expenditure on health in Australia was estimated to be $130.3 billion in 2010-11, up from $77.5 billion in 2000-01

The two largest components of the increase in health expenditure were public hospital services, which grew by $2.2 billion in real terms, followed by medications ($2.1 billion).

In 2009–10, the estimated national average level of expenditure on health was $5,251 per person.

Western Australia ($5,128 per person) was 2.3% below the national average,

Northern Territory’s ($6,549 per person) was 24.7% higher than the national average. T

The average annual real growth per person was highest in South Australia and the Northern Territory (4.3%) compared with the national average of 3.9.

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Disease statistics

Cancer is Australia’s leading broad cause of disease burden (19% of the total), followed by cardiovascular disease (16%) and mental disorders (13%).

Around 1 in 5 Australians aged 16–85 years has a mental disorder at some time in a 12-month period, including 1 in 4 of those aged 16–24 years.

The burden of Type 2 diabetes is increasing and it is expected to become the leading cause of disease burden by 2023.

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Disease statistics

Tobacco smoking is the single most preventable cause of ill health and death in Australia.

Rates of sexually transmissible infections continue to increase, particularly among

The perinatal death rate of babies born to Indigenous mothers in 2007 was twice that of other babies.

It is estimated the number of people living with dementia is projected to triple to around 900,000 by 2050. Dementia is one of the major reasons why older people enter residential aged care or seek assistance from community care programs.

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Performance: How are we doing internationally? Australia’s health system is

amongst the best in the world

However, there is still room for improvement

Australia’s economy remains strong in comparison to others – especially Europe and USA

WA does well economically

Evidence suggests that it is often difficult to make changes during

times of plenty!

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Achieving reductions in spending Ireland, achieved through cuts in wages or the fees paid to

professionals and pharmaceutical companies, and through actual reductions in the number of health workers.

Estonia cut administrative costs in the ministry of health and also reduced the prices of publicly reimbursed health services.

Investment plans have also been put on hold in a number of countries, including Estonia, Ireland, Iceland and Czech Republic

Efficiency gains pursued through mergers of hospitals or ministries, or accelerating the move from in-patient hospitalisation towards out-patient care and day surgery. The use of generic drugs has also been expanded in a number of countries.

Increase in out of pocket payments. For example, Ireland increased the share of direct payments by households for prescribed medicines and appliances, while the Czech Republic increased users’ charges for hospital stays.

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Australian Health Outcomes: OCED data suggests: In-hospital case fatality rates within 30 days of admission

for acute myocardial infarction (heart disease) are significantly lower than the OCED average (3.2% vs 5.4% in 2009).

Australia had a higher rate of death in hospital following ischaemic stroke (5.6% vs OECD average of 5.2%)

Avoidable hospital admissions for (Chronic obstructive pulmonary disease) COPD and asthma complications are higher in Australia than the OECD average. For COPD Australia rate was 312 per 100,000 adults (OECD average 198) and asthma admissions, Australia was 67 (OECD average of 53).

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Rising obesity pushing up healthcare spending % of obese among adults

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Comparison of seven nations

Davis, K. Schoen, C. and Stremikis, K. (2010) Mirror, Mirror on the wall, how the performance of the U.S. health care system compares internationally 2010 update, The Commonwealth Fund

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Why the growth in demand for primary care?

Increasing availability of medical cures and technology (surgical techniques, anti-depressants, etc)

Rising need for community-based care to support people with long-term health problems (chronic disease management)

Desire to contain costs and avoid hospitalisation Changes in hospital care leading to shorter stays and

associated need for more community support

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Why strengthen primary care PC orientation is proportional to health outcomes

The more PC orientated, the higher the health indicators rankings

Countries that are more PC orientated have lower overall costs for their health services

Their efficiency is higher

Unplanned primary care – out-of-hours care, emergencies, links with unplanned care in other sectors

The desire for better access – longer opening hours, more providers, patient choice, better pathways and diagnostics

Improving care for people with long term conditions – better pathways, managed care approaches, reducing hospital admissions

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So what did are the overall policy and management challenges facing primary care?

Dealing with the increasing levels of chronic disease

Responding to changing societal and policy demands re access and choice

Developing more integrated forms of care that are community based and yet supported by specialist services

Addressing profound workforce pressures, especially in rural and remote areas

Assuring quality of care

Addressing issues around equity and access to services

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Health Care Reform: why?

In 2008, the Australian (Labor) Government set up the National Health and Hospital Reform Commission (NHHRC) to conduct the most comprehensive review of the health system in 20 years (MCL part of wider reform)

The current health care system was identified as being: • fragmented, contributing to cost-shifting between different

levels of government• involved too much waste • resulted in long waiting times for patients.• Services are provider rather than patient led• Inequities in health outcomes• System can’t continue with increasing pressures and

demands

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Health Care Reform: why? Unlike hospitals primary care

often lacks the investment to take a system approach.

patients often feel that their journey through a complex health system could be better coordinated and many patients, particularly those who are socially disadvantaged. - For these patents the system we have come to rely on doesn't meet their needs.

There are also gaps and inequities in access to services and variations in health outcomes between different population groups

A failure of the system to focus more seriously on disease prevention and health promotion activity.

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Health Care Reform: why?

GPs and other community providers need more support so they can have an effective, central and ongoing role in patient care.

For many GPs balancing day to day practice responsibilities and trying to reform PC and they system more widely is singularly impossible.

MCL reform allows focus on system reform.

MCL can better support GPs and their practices.

This support needs to be locally or regionally based because that's where most services are provided.

The increased demand of an ageing population is unsustainable over the longer term.

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Medicare Locals: the vision Medicare Locals (MLs) New organisations first phase 2011

61 nationally; 8 in WA

Formed as key primary health organisations as a result of COAG (Council of Australian Governments) National Health Reforms agreed to by both the Commonwealth and State Governments

MLs build on previous work of the Divisions of General Practice, (working with GPs) BUT broader than GPs

Broader primary health focus - including allied health, pharmacists, specialists, nursing, mental health, preventative health

Also better linking with the hospital and aged care sectors

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Health Care Reform Cont.

120 - Divisions of General Practice

61 – Medicare Locals

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Medicare Locals: the broader role

Can build on the work of GP divisions-

Work with Broader system -stronger engagement across the whole primary health spectrum

Linkages – acute and aged care

Extra funding – fill service gaps

Community specific needs solutions

Help support research and development in PC

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MCL Five strategic objectives:

Improving the patient journey through developing integrated and coordinated services

Provide support to clinicians and service providers to improve patient care

Identification of the health needs of local areas and development of locally focused and responsive services

Facilitation of the implementation and successful performance of primary health care initiatives and programs

Be efficient and accountable with strong governance and effective management.

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Medicare Locals: the reality Young organisations just finding

their own role and identity

Various stages development, but the momentum is significant in places

Some misconceptions about what the reform is attempting to do and poor communications on what the reform is about- by

Lack of understanding of the role of MCLs

Issues around competing interests of stakeholders

Other system incentives – e.g. funding mechanisms

It is all about relationships - Variation across MCL’s – some engaging well others less well

What’s gone before matters!

Lots of mixed feelings about MCL reform– from GPs, NGOs and other groups

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Medicare Locals: the reality

Examples of local solutions that are strengthening General Practice in some regions

Health Pathways – 10 MCLs working in this space

Diabetes planning 

Work around out of hours,

Use of spatial information planning to identify gaps in services

Provision and support of important but often under-resourced or less profitable services- e.g. street Doctor

How close to medical practices is the population older than 65 that need assistance?

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Opportunities for MCLs and primary care

1.Demonstrate leadership and promote innovation in primary health care.

2.Improve the coordination and integration of primary care activities.

3.Identify needs and gaps in the local community with a focus on social inclusion.

4.Develop locally focussed and responsive services.

1.Work in partnership with key stakeholders to improve the quality of primary health care.

2.Help to drive system reform

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Delivering on the reform: what will this take? Strong and effective leadership

that can negotiate the complex and often difficult healthcare terrain

Engagement with key stakeholder groups from across the health system

Understanding of the different cultures and incentives that operate in the system

Clarity of role and communication on this

Support of the primary care sector

A passion to succeed

Commitment to improving public and patient health and a way to communicate this to the wider community

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The cost of not moving forward

At best we keep the status quo

Primary care continues to lack capacity to really influence system reform

Fragmentation and inequities grow

The evidence base around efficient and effective high quality service provision in primary care remains low

MCL experiment fails and opportunity is lost

Other?

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