Over the months that followed its election on 24 November 2007, the Rudd Labor Government proceeded to deliver on the series of health care commitments it had made during the election campaign.1 Australia saw the establishment of a National Health and Hospitals Reform Commission (NHHRC)2 and taskforces to develop a National Primary Health Care Strategy3 and a National Preventative Health Strategy,4 the latter of which will in the first instance focus on influencing major reductions in the diseases caused by obesity, tobacco and alcohol.5 The success of each of these reforms is dependent on effective engagement with Australian general practice.

The final recommendations of each of these strategies will start to be rolled out over the coming months. This will be a time of critical challenge for primary care in Australia as the ideas contained in the strategies become framed as policies, and as incentives and penalties are developed to promote their implementation. This will also be a time of great opportunity for Australian general practice. Dr Christine Bennett, Chair of the NHHRC, has stated that

These expected strategies are accompanied by other reforms initiated by government. In November 2008, the Council of Australian Governments (COAG) agreed to a package of health reforms,7 including the National Partnership Agreement on Preventive Health to improve the health of all Australians, which included the establishment of a national preventive health agency, and the National Partnership Agreement on Hospital and Health Workforce Reform, which provides the single largest investment in the health workforce ever made by Australian governments, with the Rudd Government investing $1.1 billion towards training more doctors, nurses and other health professionals.8

As part of the Australian Government’s commitment to reduce the 17-year life expectancy gap between Indigenous and non-Indigenous Australians, and in response to calls at the 2020 Summit,9 the government launched the National Indigenous Health Equality Council in July 2008,10,11 and in November 2008 announced a $1.6 billion investment by COAG in the Indigenous Health National Partnership, which expands primary health care and targeted prevention activities.12 Another example of the government’s renewed invigoration of primary care approaches to public health concerns was the establishment in March 2009 of a new ministerial advisory body on the national response to blood-borne viruses and sexually transmissible infections, including HIV/AIDS, viral hepatitis and chlamydia.13

These health reforms in Australia are taking place against an international backdrop of increased awareness about the need to strengthen primary health care in all nations, in order to address the current and looming health care challenges of the 21st century. In May 2008, the Director-General of the World Health Organization, Dr Margaret Chan, reaffirmed the WHO’s commitment to primary health care and described the consequences of “decades of failure to invest in fundamental health infrastructures, services and staff”.14 The 2008 WHO World Health Report was devoted to primary health care reform; titled Primary health care — now more than ever, it called on all nations to reinvigorate primary health care to better meet the health care needs of all people.15 At the same time, the Lancet issued a special edition on primary health care carrying the title Alma-Ata 30 years on. “Health for all need not be a dream buried in the past” and including a call for the integration of personal health care and public health at the level of the local community.16 The landmark report from the WHO Commission on Social Determinants of Health was released in August 2008; titled Closing the gap in a generation,17 the report makes a compelling call for close attention to health in all government policies. It describes how “gaps in health outcomes are ... indicators of policy failure” and champions “primary health care as a model for a health system that acts on the underlying social, economic and political causes of ill health”.14

There are important lessons in these reports for the health care reform process underway in Australia, including the need for equity in primary health care reforms18 and for the primary care sector to become part of the movement to change the wider physical, social and economic environments that support healthy behaviour, in addition to our work aimed at changing the behaviour of individuals.19

These moves towards major reform are now occurring against the background of the global financial crisis, as Australia and the rest of the world move into a period of economic recession. Global recession is likely to have serious effects on the health of the most disadvantaged, including the unemployed and the working poor.20 The recession is also expected to delay the implementation of many of the bold plans of the federal Labor Government. However, history has shown us that times of crisis also provide opportunities for remarkable, nation-changing leadership. The financial crisis, coupled with a federal government committed to equality of access and opportunity for all people in Australia, could see the stimulus for even more dramatic reforms than those expected in the forthcoming final reports of the NHHRC and the taskforces. The recession provides the opportunity to be creative at a time of limited resources and still achieve effective change.

Achieving health care reform is more complex than just expending large amounts of cash to bring about desired changes. A recent example from the United Kingdom is the less than brilliant result of the allocation of billions of pounds to the Connecting for Health initiative of the National Health Service (NHS) which, while achieving success in some areas of e-health reform, has not yet delivered all that was promised.21

The Australian Government will face a serious challenge in integrating the recommendations of the NHHRC, the taskforces and its other health reform initiatives. It is hoped that serious consideration will be given to integration before the release of any final reports. The reform process will be hampered if mixed messages, especially concerning implementation of reforms, appear in the various government reports. There is also the risk that recommendations will be pitched at too high a level and will fail to generate real and practical reforms across the health system.

One area of speculation has been around the future of Australia’s network of Divisions of General Practice and whether there will be a move towards establishing organisations that represent all of community-based primary health care,22 perhaps along the model of primary health organisations in New Zealand23 or primary care trusts in the UK, which “are now at the centre of the NHS and control 80% of the NHS budget”.24

Another serious consideration raised by the NHHRC is whether the federal government should assume “responsibility for all primary healthcare policy and funding”.6 Bringing together the cultures of the largely private primary care services funded by the federal government and the public, primary and community health services funded by the states and territories would be an extraordinary exercise in change management, but one which could achieve improvements in the coordination of primary care. Similarly, encouraging people with chronic disease to enrol with a single primary care team could enhance access to multidisciplinary preventive and chronic disease care services, and also increase the accountability of primary care organisations for the delivery of effective care to all members of their enrolled populations.22 The specific impact of individual reforms on health care provision to rural and remote communities will also need close attention, and may provide the opportunity for some exciting and inherently different models of care that could provide examples for other parts of the world.

A core part of any successful reform is the need to invest in change. Rather than governments saying “This is the new policy and we are going to enact it”, our government would be wiser to empower the members of our community and this nation’s dedicated health professional workforce to see the possibility of how we might all do things differently. Every health professional in Australia has an understanding of what their job is and how to do it well. When someone says “We’re making some changes and this is now your new role”, there is an automatic negative reaction. If reform in primary care is going to be effective, widespread and sustained, our governments need to actively engage the entire primary care workforce, respect why people entered these jobs in the first place, and harness the manifold creative abilities of Australia’s skilled and highly educated health professionals. This involves having renewed respect for professional people and their values — health for all begins with respect for all.

Reform will also bring with it ambiguities. Dealing with uncertainty and change is a core component of general practice; so is dealing with diversity and the need to be flexible. These are things we do well. They are fundamental to the nature of our clinical work. If the members of our general practice workforce can bring to the reform process the same resilience and creativity that they exhibit every day in clinical practice all around Australia, the nation could see lasting improvements in the quality, efficiency, equity and clinical outcomes of our primary care services. And that would not be a bad achievement.