On 24 November 2007, the people of Australia elected a new Labor government, which promised to reform Australia’s health system, with a strong commitment to primary health care and general practice.1,2 Following the election, the National Health and Hospitals Reform Commission was established,3 along with taskforces to develop a National Preventative Health Strategy4 and a National Primary Health Care Strategy.5

Two and a half years later, the recommendations of each of these taskforces have now been delivered. The final report of the National Health and Hospitals Reform Commission, released on 27 July 2009, focused on building on “the vital role of general practice” to strengthen primary health care as the “cornerstone of a future person-centred health system”.6,7 Following the report’s release, the Prime Minister and the Minister for Health and Ageing conducted extensive consultations with health care providers and consumers across the country. The initial focus was on hospitals, but this was rapidly followed by community-based consultations, including visits to general practices.

On 3 March 2010, Prime Minister Rudd announced the first components of the Australian Government’s National Health Reform Plan8 and advised the nation that the changes represented the “most significant reform of Australia’s health and hospital system since the introduction of Medicare”.9 In his speech, which outlined reforms to be achieved largely through funding, structural changes and national standards,10 the Prime Minister advised that the Australian Government would become the majority funder of public hospitals and take over responsibility for general practitioner and primary health care services.8,9

As the Prime Minister entered into negotiations with the states and territories and debated concerns about the continuing federal–state sharing of responsibility for public hospital funding, the attention of the media and many commentators was firmly focused on public hospitals and the establishment of local hospital networks. However, the Plan also advised that

There was little explanation provided at the time on how this would be achieved, although the Plan advised that

The Plan outlined that the move to federal funding of primary health care programs currently funded and provided by states would occur from the 2011–12 financial year.8

On 12 April 2010, stage two of the government’s National Health Reform Plan was released.11 The Prime Minister and Minister for Health and Ageing announced the establishment of a

This was followed by the federal Budget announcement on 11 May 2010 of a “$1.2 billion boost to GP and primary health care to deliver real improvements in frontline health services for patients across Australia” through the establishment of the network of primary health care organisations (PHCOs), investment in general practice infrastructure, a program to improve care for people with diabetes, and additional support for nurses working in general practice.13

Stage two revealed a modest investment of “$96 million over the next four years to increase financial incentives to GPs to provide more services to Australians receiving aged care”.11 Additional investment in aged care is welcome, but this falls far short of meeting the rising long-term care needs of ageing Australians.

The stage two report advised that the government would be making further announcements on reforms in mental health, dental health, preventive health and e-health “over the coming weeks and months”.11 The federal Budget saw the announcement of a “$466.7 million investment over the next two years ... to establish a secure system of personally controlled electronic health records”,20 but made no mention of the e-health investment needed in primary care to support the wider reforms. Only minimal further investment was announced for mental health.

Further significant reforms to support the health of Aboriginal and Torres Strait Islander peoples and the health of people living in rural and remote locations were missing, as was a specific focus on the social determinants of health, which may mean that many of the people who are currently disadvantaged in terms of health care access and outcomes will remain so. None of the announcements addressed the impact of climate change on human health, despite the World Health Organization Director-General stating that this is “one of the greatest challenges of our time”.21

The National Health Reform Plan is accompanied by other government reforms. In November 2008, COAG announced that the federal government would invest $1.1 billion in training more doctors, nurses and other health professionals.22 As a result, we now have Health Workforce Australia,23 with its mandate to ensure the nation has the health workforce to meet the current and future needs of our population, and with responsibility for overseeing the financial support for pre-professional clinical training, facilitating the clinical placement of students, and establishing health workforce registers to assist longer-term planning initiatives. The Health Workforce Australia program is expected to result in the training of an additional 18 000 nurse supervisors, 5000 allied health supervisors and 7000 medical supervisors,22 but there is little acknowledgement of the challenge of identifying and retaining supervisors. There is also no mooted increase in the practice incentive payment for training medical students in general practice, which has stagnated at $100 per session since 2004.

These challenges are compounded by the reforms arising from a review of Australian higher education,24 which will remove caps on university enrolments for many health professions at a time when training capacity in hospitals and the community is already stretched. This may be balanced by growing capacity for clinical training in non-traditional settings, such as private hospitals, private clinics and other community-based health care settings. Integration of these government reforms is essential; otherwise the reform process risks being hampered by mixed messages and clashes in implementation.

Some key aspects of reform have not yet been rolled out, such as the aforementioned delay of some GP Super Clinics. Additionally, although COAG announced an $872 million investment in preventive health programs and the establishment of a National Preventive Health Agency in November 2008,25 at the time of writing, the Bill to establish the agency was still under consideration by the Senate.

Is this all real reform or a series of loosely connected new programs and initiatives that aim to produce improvements in discrete aspects of our complex health care system, but which risk a continuation of the problems of cost shifting and blame shifting? There is a risk that the announced initiatives, while providing significant increases in funding for some aspects of primary care, may not result in a fundamental shift from a system focused on hospitals and disease to a system that focuses on community-based care, health promotion and the prevention of illness.

The recognition of and support for the central role of general practice, expressed by the government throughout the reform process, remains strong but needs to be matched by appropriate targeted investment that builds capacity in every general practice in the country. General practice is a proven, cost-efficient and effective model of care that centres on the needs of individuals and communities,26 and public confidence in general practice in Australia remains very high.27 The rush to reform must not put this at risk. We need to ensure that we do not sacrifice the personal responsibility of a single clinician, or team of clinicians, for an individual patient. Care delivery by multiple providers can provide benefits, but each patient still needs a trusted advocate who shares responsibility for the coordination of his or her care.

The commitment of our health workforce underpins the success of Australia’s health care system. The scale of the proposed change is daunting, and the nation’s health care providers will need to be supported during the coming months of uncertainty. Any reforms need to respect the commitment of each health care professional, while at the same time engaging each of us in achieving the changes our community would like to see.