Can Alberta’s primary care networks provide any lessons for Medicare Locals?

The Australian and Canadian health systems share many similarities; one author has described them as “children of a common mother”.1 The fundamentals of the provision of primary care in both countries are the same: the overwhelming majority of “general practitioners” in Australia and “family physicians” in Canada work in independent practices, billing “Medicare” on a fee-for-service basis. The structure of family practice is similar, with a mix of solo and multiphysician practices. In Alberta, patients are not required to register with a single practice, but many family practices are not accepting new patients, and so registration with a practice is universally seen as desirable. There is no financial penalty (on the patient or the practice) for patients seeing a physician outside the practice in which they are registered. There are some differences; most notably that health care in Canada is essentially a provincial responsibility operating within overall parameters set by the Canada Health Act, and that “extra-billing” (billing above the schedule fee) is prohibited.

The health systems in both countries face similar challenges in meeting the needs of primary health care: improving access, especially in rural and remote areas; better managing chronic disease; developing more effective links between primary care and hospital practice; and working out how to foster multidisciplinary teams.

Alberta’s answer to these challenges has been to develop Primary Care Networks (PCNs), which may provide useful lessons for the establishment of Medicare Locals in Australia. Alberta is one of Canada’s western prairie provinces, with a population of 3.7 million, covering a geographic area about three-quarters the size of New South Wales. In 2009, Alberta had 113 family physicians per 100 000 population (4187 family physicians).2 The first PCN was established as part of the funding agreement between the province and the Alberta Medical Association in 2005. There are currently 39 PCNs in Alberta, and about 75% of family physicians work in practices that are members of PCNs.3

PCNs are organisations of practices — the PCN itself does not enrol patients and does not run the practices. PCNs are eligible for a capitation payment of $50 per patient (for the purposes of this comparison, the Australian dollar can be assumed to be on a par with the Canadian dollar). PCNs are required to submit a “business plan” to Alberta Health Services (the provincial provider organisation responsible for the flow of funds to the PCNs) about how the capitation funding would be spent. Considerable flexibility is permitted in the structure and content of business plans, which allows for local variation in priority setting.

PCNs range in size in terms of both the number of physicians linked to them and the number of patients served. PCNs in rural areas are smaller on both dimensions.

PCN governance reflects both physician autonomy and the need for accountability to the funders (Alberta Health Services, and the relevant government department, Alberta Health and Wellness), reflected in two decision-making fora: a physicians’ board (known colloquially as the “Little Board”) and a PCN board (“Big Board”) with representatives of the funding organisations. The Big Board thus provides a direct link between the PCN and senior local Alberta Health Services leaders who are responsible for wider health issues.

The PCN budget is derived from the capitation payments used to cover administrative costs of the initiative, which include employing an executive director responsible to the Little Board, employing allied health or mental health staff (often based in individual practices), and providing other support functions (eg, supplying comparative data).

Stakeholders see collaboration as the principal benefit of PCNs, and the provision of improved access to allied health care as one of their greatest strengths. “Collaboration” is used broadly here, to refer not simply to relationships between physicians and allied health professionals but also to relationships between physicians and the rest of the health system. In recent interviews with family physicians involved in PCNs in Alberta, conducted by one of us (A S, as part of a medical student placement), one physician stated that, “The PCN initiative has saved primary health care in Alberta”. Another, who holds positions on both the Little and Big Boards of a larger PCN, stated:

There are disadvantages of the current PCN arrangements, including a lack of clarity with regard to general PCN direction, which stems from the autonomy in setting priorities granted to PCNs to allow maximum flexibility in responding to local needs.

Strengthening primary care has been a catchcry of health reform efforts around the world for decades. The most recent Australian example is the report of the National Health and Hospitals Reform Commission.3 However, primary care is complex and reform is hard to achieve. One strategy has been to attempt to strengthen primary care by developing a stronger organisational base for it — initially, in Australia, through Divisions of General Practice,4,5 and more recently, through Medicare Locals.6 Divisions have been successful on a number of dimensions,7 although the administrative arrangements at both national8 and local levels9 have not been perfect.

Arrangements for Medicare Locals are still evolving, and their evolution could benefit from taking note of similar strategies in other countries. Alberta’s PCNs have something to offer here as they have proven themselves to be a vital part of continued access to primary health care in the province.

Although the Canadian and Australian health care systems are similar, they are not identical. Some aspects that may be portable are:

• Capitation funding — means that PCNs know how much they can expect and can plan accordingly. Depending on their size, PCNs receive up to $15 million per annum to be distributed in line with business plans.

• A dual board system — provides a compromise between physician autonomy in management of the PCN while allowing delegation of some decisions to the physician group. It has some parallels to the German approach of management and supervisory boards.10

• An evolutionary approach — incorporating a slow phase-in means the system is not being imposed on any physician or practice and allows skeptics to evaluate the benefits of local cooperation. The first PCN was established more than 5 years ago, but some practices have not yet linked up to a PCN, despite the financial incentives.

Alberta appears to have invented a wheel for primary care that is supported by family physicians. Australia could learn from this example without needing to totally reinvent it.