Professor Stephen Leeder, Director of the Australian Health Policy Institute, writes:
The recent Crikey article raising serious questions about the future of primary care is timely in view of the problems facing general practice in Australia.
We need a national approach to general practice that invests five times the current level in it: to achieve best quality care; reduce inappropriate use of hospitals; reach preventive goals; and make it an attractive career for bright medical and other health professionals. General practice should be fitted with sophisticated IT for staff to communicate with other doctors, nurses, community workers and patients and with each other.
Practices should be remodelled as part of Australia’s rediscovery of the value of investment in infrastructure. This would achieve higher levels of community satisfaction and secure the future of Australia’s health service in face of mounting pressures due to ageing and chronic illness.
Beside this rejuvenation of general practice, Australia needs to stir itself and find out what is going on around the world in the field of primary health care, which goes beyond general practice to what we might call the local politics of health.
Primary health care is about how to assist communities to achieve better health and greater equity. It overlaps with, but is not the same as, general practice. There is confusion about primary care and primary health care. We distinguished the two in a recent paper in the Medical Journal of Australia recently . Primary health care is much more comprehensive, as defined by the World Health Organisation thirty years ago, and as I used it in the paragraph above.
Towards a National Primary Health Care Strategy is a discussion paper published recently by the Australian government. Congratulations to the federal government for recognising the need for a strategy in this field. The paper called for submissions on ten ‘elements that could underpin a future primary health care system.’ The paper offers no precise definition of primary health care but generally it means general practice with add ons.
So despite the title, what we have learned from around the world about the value of primary health care, extending beyond the provision of general practice to community development, energising people to assume greater responsibility for their own health and helping shape the political and economic determinants of health, is out of range of this document although not entirely so.
Yet the future of general practice and allied community support services is very important in its own right. General practice is currently maldistributed – too many practices in cities, too few in the country, too few in ethnically diverse settings – and this is the first of the ten issues raised in the discussion paper. It is the first of three practical, understand-what-you-mean issues considered in it.
The other seven issues are interesting but require changes in health policy that go further than general practice. They may appear remote and theoretical to a general practitioner looking for evidence that his or her plight is taken seriously.
The second point has to do with making primary care more patient-centred and friendly. The third point calls for more support for prevention in general practice, especially that variety that has a clinical component to it – assessing risk factors for example. Good idea, but who pays, and where does the time for it come from in a busy practice with a waiting list?
The fourth point argues for better integration with other community health services, the fifth with assuring greater quality, the sixth (another good practical one) with the use of IT. The seventh seeks more and stronger relations between general practice and the communities in which they operate, a tilt to primary health care as discussed above. The eighth, a crucially important one, concerns how to make the primary care setting more attractive for practitioners. The ninth is about education and the tenth is expressed in econojargon – and calls for fiscally sustainable and cost-efficient care.
What is happening elsewhere? In August, The New England Journal of Medicine ran a perspective paper entitled “Primary Care – Will it Survive?” from Dr Thomas Bodenehimer at UCSF. It is superbly written, with powerful word pictures of what is happening in general practice in America, with its patient and practitioner dissatisfaction, growing expectations of primary care as the tide of chronic illness rises and as the number of preventive services that people expect in general practice grows.
Meanwhile, more clinical practice guidelines are recommended, brightly telling practitioners how to do everything from managing a lump in the breast to treating blood pressure. The similarities with Australia are striking.
Everyone wants general practitioners to do everything according to their specified rules for no more money and many more forms to complete. General practitioners are encouraged to be coordinators for people with chronic illness, but as Bodenheimer points out in an earlier paper, “the number of coordination relationships can multiply geometrically in the not-unusual case of three different provider organisations (with several caregivers in each organisation) having to interact with a patient plus three distinct family members” making care coordination an industry in its own right..
Assuming about 2,500 patients are on the books of one practitioner, Bodenehimer says, it would take that doctor 10.6 hours a working day to deliver the care for those with chronic illness according to guidelines, plus 7.4 hours a day to provide evidence-based preventive services to those who pass through his or her surgery!
No wonder that with the practitioner under such pressure half the patients with hypertension, diabetes and chronic conditions leave the physician’s office not having understood what the doctor said.
All is not bleak in the U/S., especially within general practice itself, rather than the organisation that supports it. Bodenheimer points to reform in larger group practices that now work well with other health professionals in caring for people with chronic illness. His arguments for the value of reformed general practice are supported by data that demonstrate how good general practice improves both the quality of care of patients and decreases hospitalisation costs in American states where it is adequately supported.
But much of general practice, operating in small premises, is unreconstructed. He argues for reform both within and beyond general practice, lamenting the lack of a national primary care policy in the U.S. that covers reimbursement: the fortunes of general practice, he says, are dictated by a ‘specialty-rich, quantity-based reimbursement system.’
Until we come to terms with reimbursement for general practice and infrastructure renewal, vague idealism will be like a cotton bud soaked in lignocaine jammed into an aching tooth.
To reform, it will cost more, not less, to provide an excellent national general practice service. The investment may be worth it in the long term, and ‘fiscal sustainability’ might be reached eventually, but not until we have invested heavily.
An investment strategy is needed now. We need to identify the attributes of the form of general practice we need for the future and then do the hard yards of facility building, continuing education and support, recruitment, infrastructure development, IT, continuing education, human resource management, monitoring, research and evaluation. This is the way to buy in doctors and others of quality for the future and assure excellent service.
For Bodenheimer, the contract between the present and the future is this: the general practitioner of the present may come to work in the morning and say, “OK. I have 30 15 minute consultations to complete before I go home tonight.”
In the future the general practitioner will walk into his or her office and say,” With my team I am going to spend my day trying to make my panel of patients as healthy as possible.” This means using the phone, using other health professionals to do home visits, using email, Skyping, running groups, following up people overdue for Pap smears in a sophisticated, IT-enabled practice. In this way the physician may reduce his or her direct consultations to ten a day, reserved for the most complicated patients who really require the skills of their physician for their problem resolution.
Alongside more roads, more train lines, and more ports, Mr Rudd and colleagues should consider opportunities for spend, spend, spend in health infrastructure. Public hospitals could soak up several billion dollars in long-overdue refits. A parallel investment in primary care infrastructure, way beyond the few dozen Super Clinics in the vast expanse of general practice in Australia, should fund general practice refurbishment that restores patient confidence and practitioner satisfaction in general practice Australia wide.