Two views on primary health care highlight shared goals
With consumer health leaders this week putting the case to Health Minister Greg Hunt for consumer-centred primary care, we have invited two advocates of primary health reform to respond to our questions about the big challenges for primary health care. Geoff Bartle a health consumer who understands that a holistic approach to healthcare is essential, and serves as a consumer representative on a number of State and National Review and Advisory committees. Dr Wally Jammal is the principal GP in a family practice in Sydney, supervises GP medical students and registrars, and sits on various MBS review committees and the Medicare Services Advisory Committee among others.
The result? Two distinct perspectives but also with many shared themes of partnership and integration. Here’s what they have to say.
1) What are the shortcomings as you see them of the primary health care system we have now?
- Accessibility and lack of capacity particularly outside cities.
- Fragmented, often silo-based and duplicated services
- Affordability gap between those who can afford health care and those who can’t
- Health professionals are enablers but responsibility for a person’s health must reside with the individual regarding exercise and diet - patient support is required to embed that responsibility
- Support needed for a holistic approach to collect and share patient information, to overcome information repetition to providers through a personal health record.
WALLY JAMMAL: Primary health care is underpinned by a wonderful GP-patient relationship. However, effectiveness is limited by silos of care, poor coordination, lack of effective team-work, and a “firewall” of information between its different parts and hospitals. This can contribute to suboptimal care, duplication of services, waste of resources, and often disjointed, unpleasant consumer health journey. Limitations in data linkage and availability hinder improved PHC.
2) What are the three top priorities for PHNs to improve primary care?
- Supporting integrated and coordinated care through multidisciplinary health teams, navigable pathways and better use of technology; improving services for the whole community, recognising in particular the challenges experienced by aged, indigenous and CALD members.
- Needs-based patient centricity through genuine involvement of consumers in priority setting, design and commissioning of services and programs – must not be tokenistic
- Supporting a stronger focus on effective preventive measures and support. Self-management and prevention, particularly through smarter lifestyle choices by individuals, their carers and often parents, should also be a key area of focus to minimise the need for health care, thereby reducing costs. Individuals and the community need to be supported to be healthy from the beginning.
WALLY JAMMAL: PHNs play a vital role in improving the capacity and quality of primary care. From a GPs perspective, they should be able to provide resources and expertise to improve:
- Training and capacity for data gathering and linkage for the purpose of continuous quality improvement
- Resources, training and levers for better care coordination, as well as linkage with the tertiary health sector at local health level
- Linkage of different parts of the PHC system to better enable care coordination, with co-commissioning across public and private system silos.
3) What do you see as the strengths of the Health Care Home Programme and what potential does this service model have to strengthen PHC?
GEOFF BARTLE: Provision of coordinated care through teams, including allied health care professionals and other service providers whom patients/carers consider important to their health and well being.
- Support for patients to be more responsible with their health management through involvement in development of joint care plans
- Better medicines management
- Improved affordability through provision of care based on patient’s needs, and where patient and/or carer and family are integral to developing a coordinated approach appropriate to their needs.
Potential is to develop truly integrated patient-centric care where all relevant providers who the patient requires/requests are working together so each knows what they are providing, when they are providing it and how they are providing it in order that care is delivered in a holistic and complementary manner which supports patient recovery, wellbeing and capacity-building for self-management and prevention.
WALLY JAMMAL: The HCH programme has many strengths, its greatest being its fundamental principles behind the “Ten Building Blocks” of high performing primary care. These include:
- Calling upon general practice to show transformational leadership and improving the quality of its work;
- Partnering with consumers and their families to better coordinate their care, a partnership which is underpinned by the registration basis;
- Encouraging primary care to undertake data driven quality improvement;
- Encouraging team based care to obtain the best out of people;
- Care coordination;
- Population management with a focus on identifying gaps in care and chronic disease management; and
- A different model of funding to enable care innovation and “unshackling care” from the current fee for service system
When combined with measurable outcomes focused on patient reported measures (outcomes and experience), these things have immense potential work to strengthen primary care and the existing bond between primary care and consumers.
4a. What role should consumers and consumer advocates play in improving primary care?
GEOFF BARTLE: Representation and promotion of consumer interests.
- Encouraging increased patient responsibility for their health and wellbeing through self-management, but with appropriate support tailored to their requirements
- Contributing to an increased focus on effective preventive care
- Working with planners and designers to ensuring services and investments are targeting priority areas and geographic locations, and that they are designed and delivered in a manner that patient based, and is appropriate to the local context and cultural conditions.
- Patient centricity cannot just be rhetoric – consumers and advocates have a legitimate role at the table and must be involved in genuine decision making. Otherwise their inclusion is tokenistic.
4b. What role should doctors and medical advocates play in improving primary care?
WALLY JAMMAL: The medical profession needs to keep central its vision of health care for all. With consumers and their carers, we are the custodians of the health system. The key to success is integration and transparency:
- Integration of people, ie having different health professionals working side by side (in person or virtually), with all care being transparent to the consumer
- Integration of systems, again with visibility to the consumer
- Integration of data and information, so that everything that is known about the patient, is known to the patient
- Integration of funding, so that funding silos are broken down and investment in primary care is value driven
5) Resourcing: how much more is needed to make a real change to primary care?
GEOFF BARTLE: Resources are not limitless. Rather than relying on increasing resources, there must be more collaboration between providers, greater coordination and rationalisation of services, thereby reducing duplication and achieving efficiencies.
- More resourcing is required to achieve true patient centricity through the right balance of consumer representation in terms of age, gender, cultural and relevant skills and experience. This means adequate compensation must be provided where appropriate to ensure that consumer representatives are not financially disadvantaged if taking time out of their normal roles to make a contribution.
- Attitude and model change to being really patient-centric rather than increasing resources, and stocktaking and realigning all relevant initiatives for delivery with patient care, wellbeing and health being the primary focus; i.e. lift the debate and focus above impact on medical professionals, health providers and self-interests of the health industry.
WALLY JAMMAL: Every part of the health system cries out for more funding, and primary care is no exception. It is always important, however, to realise that much more investment is required in primary care. This investment should be directed towards the parts that demonstrate value and high performance. It is also important to remember that it is the entire health system that benefits from high performing primary care, with greater investment “upstream” in primary care preventative services generating “downstream” (tertiary) savings.
5) What priority should be given to training for consumers and GPs to drive improvements?
- Innovation and technology is driving change in health services delivery and design. As recipients of new services and tools, consumers will increasingly need support and training in making best use of what is available to manage their conditions, and also to be more focused on prevention.
- Consumer representatives are playing an increasingly important role in highlighting areas of need, and being involved in the co-design of relevant services. With increased data availability and technological applications to enable improvements, representatives need to be supported with relevant training to equip them with the skills, confidence and knowledge to make an effective contribution.
WALLY JAMMAL: Reforming and improving primary care, especially around the changes that surround the HCH programme, requires a paradigm shift in thinking, both amongst consumers and GPs. Training for consumers needs to be focused on the workings of the system, the benefit it brings, as well as the vital role they play in driving quality improvements (by understanding what good care looks like) and demanding transparency. Likewise, GPs need to understand that a different way of funding requires a new way of working. We must “let go” of the innate feeling that we must do everything ourselves, encourage our colleagues and teams to work to the best of their ability, and empower consumers to be as much a part of their own health care as possible. Improvement in primary care is all about partnership with care teams and with consumers to get the best possible healthcare.