“The focus of chronic disease funding needs to move away from a fee-for-service payment to doctors, towards a broader payment for clinics to practise integrated care.
The evidence shows that a consistent approach to clinical care pathways for specific chronic diseases can make a real difference to outcomes. And for that, we need much greater investment in supporting service development and innovation in primary care.
It’s not more money that’s needed. What we need is better organisation, incentives and management of primary care.”
Hal Swerissen Fellow, Health Program, Grattan Institute and Stephen Duckett Director, Health Program, Grattan Institute as published in The Conversation
“Statistics on hospitalisation provide some insights into ill-health in the population [1]. They are, however, a fairly poor reflection of the extent and patterns of treatable illness in the community because they only represent illness that is serious enough to require hospitalisation and are influenced to some degree by the geographic accessibility of hospitals and variations in admission policies.
Potentially preventable Indigenous hospitalisations are admissions which ‘could have been avoided with access to quality primary care and preventive care’ [8]. Rates for potentially preventable hospitalisations, including those for chronic conditions and vaccine-preventable conditions, may be used as an indirect measure of problems with access to care and effective primary care.”
Hospitalisations Healthinfonet
Each year the Australian government spends at least A$1 billion on planning, coordinating and reviewing the care of people with chronic diseases, such as diabetes and heart disease, in general practice.
Yet there are more than a quarter-of-a-million hospital admissions for health problems that potentially could have been prevented by better primary care for chronic disease.
Our report, Chronic Failure in Primary Care, published today, argues that primary care services are not working anywhere near as well as they should because the way we pay for and organise them through Medicare goes against what we know works.
Australia’s health system was designed to deal with infectious disease, wars and accidents. But the most significant burden on the health system today is chronic disease.
High cost of chronic disease
Three-quarters of Australians over the age of 65 have at least one chronic condition that puts them at risk of serious complications and premature death. Around 90% die from a chronic disease.
Six chronic conditions – heart disease, oral health problems, mental disorders, musculoskeletal conditions (including arthritis), respiratory disease (including asthma) and diabetes – account for about half of the total disease cost.
Most people with these conditions are seen by general practitioners in the primary care system. But we are failing to prevent and successfully manage chronic disease in primary care.
For example, about a million Australians have diabetes. These people have a two-fold higher risk of dying from heart, kidney and peripheral vascular disease (the latter from reduced blood circulation) than the general population.
They need help managing diet, exercise, smoking and alcohol use. They also need appropriate medication and regular monitoring. Primary care provided by general medical practitioners is the best place to get help.
However, analysis done for our report showed that only about a fifth of people with diabetes who see a GP have their blood pressure, blood sugar and body mass recorded each year. Only about 20% of these patients reach recommended clinical targets. Often, they get little in the way of advice or support for self-management.
The story is similar for other major chronic diseases including heart disease and chronic respiratory disease. Often, less than half of people with chronic disease get the care that is recommended. This results in much poorer patient outcomes than could be achieved.
Ineffective management of chronic conditions in primary care leads to worse health outcomes and higher costs.
Potentially preventable hospital admissions are estimated to be 7% of all admissions, 9% of hospital bed days and cost up to A$2 billion each year. Even if we use the more realistic estimates developed for our report, the costs are A$322 million per year.
Chronic disease support is already well-funded
The Commonwealth has tried to fix the problem by introducing assessment, planning, coordination, team management and review payments for GPs to better manage chronic disease, including mental health.
More than A$1.7 billion was spent on systems management, care planning and coordination for primary care in 2013-14. This included A$904 million for health assessment, management of chronic disease and mental health, and incentive payments for asthma and diabetes.
Practices received A$210 million in practice incentive payments to support infrastructure development and better practice. An additional A$661 million was spent supporting GPs and primary care through regional primary care networks, Medicare Locals (now Primary Health Networks).
Prevention and management of chronic disease in primary care is not easy. It requires sustained effort by people with chronic conditions working in partnership with a team of health professionals. The role of GPs is vital. Care must be planned rather than reactive; it must focus on the patient, rather than on health professionals, and it must focus on outcomes.
In Australia, the split in Commonwealth and state responsibilities has made good-quality prevention and care for chronic disease more difficult. The states are mainly responsible for public hospitals and the Commonwealth is responsible for GPs and primary care. As a result, the system for preventing and managing chronic disease is fragmented.
Performance targets are largely absent. There is little agreement about local care pathways, which guide how patients should be treated. Funding incentives are poorly designed and there is only limited support for service innovation and improvement.
So what’s the solution?
The focus of chronic disease funding needs to move away from a fee-for-service payment to doctors, towards a broader payment for clinics to practise integrated care.
The evidence shows that a consistent approach to clinical care pathways for specific chronic diseases can make a real difference to outcomes. And for that, we need much greater investment in supporting service development and innovation in primary care.
It’s not more money that’s needed. What we need is better organisation, incentives and management of primary care.
Existing Medicare funds spent on assessment, planning, coordination and systems development could be reallocated as follows:
- regional Primary Health Networks, which are already in place, should be strengthened
- health pathways that have been developed in New Zealand, the United States or Europe could be adapted and implemented in Australia
- established service development models such as the Australian GP Collaboratives could be extended to all areas.
The prevention and management of chronic disease is an urgent problem. Broader social and economic measures have the greatest potential for future prevention. But a consistent and coherent plan for primary care is urgently needed to manage the problem for people who are already at risk or have chronic disease now.
Response from
CATHERINE KING MP, SHADOW MINISTER FOR HEALTH
GRATTAN REPORT A WAKE UP CALL ON PRIMARY CARE
The Grattan Institute’s report on primary care highlights the need for smarter and better investment in primary care, and for the Turnbull Government to end its war on general practice.
The report finds ineffective management of heart disease, asthma, diabetes and other chronic diseases leads to more than a quarter of a million avoidable hospital admissions every year, costing the Australian health system at least $320 million. The report notes that other estimates are as high as $2 billion a year.
All of the evidence internationally is that the stronger a country’s primary care system, the better its health outcomes are.
We know from a number of studies that health systems with strong primary care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes including lower mortality, than those that do not.
It is especially disappointing therefore that general practice has been so continually devalued and attacked by this Government though its GP Tax, four year Medicare freeze and massive cuts to heath.
In Government Labor encouraged new models of practice through the introduction of bundled Medicare payments for the treatment of chronic disease, established GP Super Clinics which integrated allied health workers into general practices and established of Medicare Locals to continue to reform primary care at the local level.
Labor also commenced work on developing an Australian model for patient-centred medical homes and developed the National Primary Healthcare Strategy.
All of this reform work came to a grinding halt with the election of the Abbott/Turnbull Government. For example, the Grattan report notes that the Turnbull Government’s decision to break its election promise and abolish Medicare Locals means that Primary Health Networks “are still new and most currently do not have the capacity to take on the roles proposed”.
So far all we have seen are cuts to primary care, a multitude of reviews and short term Budget savings placed ahead of long term investment in health. Australians deserve better than a Government which only ever sees health as a source for Budget cuts. Only Labor believes in Medicare, and only Labor will protect Medicare and build the health system for the 21st Century that Australian deserve.
MONDAY, 7 MARCH 2016
RACGP calls for fact not fiction in health debate
The Royal Australian College of General Practitioners (RACGP) has challenged the findings of a Grattan Institute report on chronic disease treatment in primary care.
RACGP President Dr Frank R Jones said the Chronic Failure in Primary Care report referred to old data, some of which dated back 10-15 years, and was selective in its representation of the issues.
‘Health systems in every country are struggling with the changes in health demography and finding the most cost-effective modus operandi. We need to carefully appraise overseas models and only apply them in an Australian context,’ Dr Jones said.
‘We need Australian solutions to Australian problems – frontline GPs see the challenges daily and are central to any informed debate about the best way forward.’
The RACGP released its Vision for general practice and a sustainable healthcare system last year, which highlights solutions to some of the problems identified in the Grattan report.
‘Our model sets out a vision for implementing the patient-centred medical home in Australia, by improving coordination and integration of care, particularly for patients with chronic disease.’
Dr Jones said the RACGP agreed there was an issue in managing chronic disease in Australia, however the statistics reported by the Institute were not new; people are living longer than ever before and as a result, people are living with more complex health conditions for longer.
‘The Grattan report suggests that there is significant funding allocated to support chronic disease care, and suggests inherent system inefficiencies,’ Dr Jones said.
‘From a GP perspective however, the Productivity Commission Report released last month revealed that general practice continues to be the most efficient part of the health system.
‘The continued focus on finding savings in general practice itself is a misconception when general practice accounts for just 7% of overall government spending on health.
‘Of course, there is opportunity to use scarce health dollars more efficiently across the health system. But it requires investment in quality general practice, not the imposition of red-tape and suspect overseas models.’
Recommendations to increase the role of Primary Health Networks (PHNs) to manage primary care services was also of concern.
‘Where is the evidence that PHNs will improve patient outcomes and experiences of the health system?’ Dr Jones said.
‘PHNs may help fill gaps in patient services, and connect health professionals. We all want to improve our patients’ outcomes, none less than GPs and the RACGP, so let us all work in constructive collaboration for the common good.
‘A patient-centred medical home with appropriate recognition of quality continuity and contextuality is undoubtedly the best way forward, and PHNs need to embrace and support GPs in this endeavour.’
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