Updated: May 10, 2019
Recently I presented an overview of the policy context and opportunities for primary care in Australia to the West Australian Primary Health Alliance (WAPHA). I’ve put a link to an edited version of the presentation here.
The presentation highlights the dramatic rise in the importance of chronic disease for primary and community services and the rising community expectation that services will be available to support people at home and in the community.
Social change has put pressure on informal care and support provided by families. Not surprisingly there has been a dramatic expansion of primary and community care services in an attempt to fill the gap. But these services are fragmented, siloed reactive and patchy in their distribution.
There needs to be much more emphasis on comprehensive, integrated care available after hours and at home. In particular, services need to much more proactive and focused on prevention, early intervention and the ongoing support of people with complex conditions.
The presentation suggests a new form of organisation for primary care: Integrated Health Groups. These groups would bring together general practice, pharmacy, nursing and allied health for populations of around 30,000 to 50,000 people. Big enough to have the scale to provide the staff, systems and coordination for integrated care and small enough for maintain relationships between providers, patients and the community.
Primary is expanding and likely to grow further in the future. So is community and home support for older people and people with disabilities. But there are significant concerns that our primary and community care system is not fit for purpose and won’t deliver the outcomes the community expects.
Contemporary primary care in Australia has its origins in the development of Medibank by the Whitlam Government. Medibank set up a capped funding stream for public hospitals shared with the States and an uncapped rebate scheme for community medical and pharmaceutical services. Medibank aimed to provide universal access to health services based on need rather than ability to pay. Medical and pharmaceutical rebates now provided through Medibank’s successor, Medicare, underpin general practice, local pharmacies and specialist consultations.
Over the last 50 years, the other significant policy trend has been the move away from institutional to community care for aged care, disability services and mental health. Most significantly we have seen the development of the home and community care program for older people by the Commonwealth; deinstitutionalization of services for people with disabilities and mental illness by the States; and the more recent establishment of the National Disability Insurance Scheme. Primary and community care has expanded dramatically and become much more complex.
A number of factors have driven the expansion and change for primary and community care. Social and economic change has seen a major increase in women’s participation in the workforce. Families are smaller, and people are more geographically mobile. Not surprisingly, paid work is replacing informal care, especially for women.
With reductions in infectious disease and trauma and increased life expectancy, there has been an expansion of chronic disease. Most people now die from chronic diseases like cancer, cardiovascular disease and neurological disease. Non life threatening conditions including musculoskeletal conditions, vision and hearing problems and autoimmune diseases have become much more prevalent. Cure is difficult and prevention and management are the main focus.
The baby boomers are ageing. This increases the expansion of chronic disease. Additionally baby boomers are more educated, affluent and demanding. They are less tolerant of inflexible, inefficient and inadequate care. They want a greater say over how and where services are delivered.
Information, communication and health care technology makes it much more possible to provide more complex services at home and in the community. These technologies are still emerging and service delivery models have not yet adapted to use them efficiently and effectively compared with other service sectors. Increased ‘uberisation’ of primary and community care is likely.
Over the past 50 years primary and community care has become a large and increasingly complex part of the health and long term care system, as our recent report on mapping primary care shows. It now makes up about a third of all health expenditure.
There have been debates about the purpose and characteristics of primary care, primary health and community care. Primary care is usually thought of as treatment, support and care services provided at home and in the community for people who ill, distressed and need support. Primary care includes secondary prevention services for people who have problems or are at risk of developing them. They are also seen as the gateway to more complex health and social care.
Primary health care is a broader concept that includes primary prevention as well as primary care. Primary prevention addresses the social, economic, cultural and environmental issues that result in health and social problems. Community care includes a broader range of rehabilitation and social support services to assist people to live at home and participate in community and employment activities.
There will be a massive expansion of primary and community care over the next three decades as the population ages and the National Disability Insurance Scheme is fully implemented. It is also likely that there will be ongoing pressure to improve access to better quality mental health and alcohol and drug services,
But with expansion, a number of issues have emerged. Primary and community care is made up of a large number of small scale providers, including GP practices, pharmacies, community health services, home and community care providers and so on. There are multiple payment, funding and regulatory models for these services. Referral and coordination arrangements between providers is highly variable and complex. There is little in the way of regional or local system planning, coordination and management. As a result there are significant geographic and financial barriers for people to access services, depending on what they need. For people with complex and ongoing needs in the community, services are often poorly organised and coordinated.
Overtime as services in the community have expanded and become more complex, there has been a blurring of the boundaries between primary health, primary care and community care. It is now more sensible to see primary and secondary prevention, treatment, care, rehabilitation and social support services as an integrated system that needs to be planned, coordinated and managed for particular communities and geographic catchment areas.
There is widespread recognition that primary and community care services need reform. They need to be more responsive, effective and efficient in meeting the needs of the growing number of people with complex, ongoing needs so they can continue to live at home and participate in the community. Barriers to service access, including their cost, geographic location and eligibility criteria, need to be addressed. The coordination and quality of services need to be improved and more emphasis on prevention and early intervention is required.
The Commonwealth has taken a number of steps to address these issues. It has introduced the NDIS to expand services for people with disabilities. There is a much greater focus on consumer directed care. Home and community based services for older people have expanded. Area based planning, development and commissioning has been introduced through Primary Health Networks.
But significant issues remain. People on low incomes continue bear high out of pocket costs for dental services and specialist medical services, a problem compounded for people with complex ongoing conditions. There are not enough mental health and alcohol and drug services. There are shortages for a range of services in rural areas and it is often difficult to recruit staff. Systematic approaches to organised, local, primary and secondary prevention are almost completely absent. Planning and coordination across primary and community care and acute and residential care remains fragmented and variable. As a result people’s experiences and outcomes are worse than they could be.
In the future, a number of trends are clear. Demographic change, particularly population ageing will drive expansion of primary and community services and ageing baby boomers will demand better and responsive services.
The digital revolution will see information, communications and treatment technology increase the delivery of a greater range of services at home and in the community. It will also make delivery of these services in more dispersed rural communities possible. More functions and services are likely to transfer from hospitals and residential care to home and community care.
Expansion and consumer demand will increase pressure for better local planning, coordination and management of the service system. New forms of service organisation and models of service delivery will be required, particularly for people with complex and ongoing needs. The current model of small scale, professionally focused practice does not have the scale and competence to independently provide comprehensive primary and community care.
Alternatives include corporatisation, or expansion by not for profit extended care organisations, community health organisations or hospitals to provide primary and community care, or the development of new organisational forms like GP practice networks. There are already a number of examples of corporatisation and aggregation, including the recent mergers and expansion of nursing services. There is also an ongoing explosion of community care organisations in response to increased funding for home and community care for older people and people with disabilities.
These trends will drive demands for better service models. Access to services will need to be streamlined and simplified. Organisations will need to able to deliver high quality, efficient, comprehensive health and social care tailored to individual needs and preferences. Services will need to be available seven days a week and 24 hours a day. They will need to be responsive, including rapid crisis support. They will need to be accountable for service outcomes and the experience of service users.
For individual practitioners this will mean a much greater emphasis on working in well coordinated teams to provide services for particular groups of patients or clients. New roles are likely to emerge, particularly for the coordination and management of teams and their outcomes. Skill sets are likely to become more modularised and transferrable across practitioners allowing more flexible role expansion and specialization.
Of course the future is never certain. Mostly, with occasional exceptions, change is incremental. But some trends are clear. Preferences for long term care, including end of life care, at home and in the community are strong. Demand for primary and community care is highly likely to increase. Consumers will want greater rights and choice over services. Increasing digital disruption is certain. The challenge will be in how government policy responds.