Our first National Primary Health Care Strategy: 3 years on, what change for general practice?

E-health: Medicare Benefits Schedule (MBS) items and incentives for general practitioners and specialists using videoconference consulting outside metropolitan areas and in residential aged care have been introduced, although access to these was reduced last year to rural and residential care only. In 2012, 17 549 videoconference consultations were undertaken nationally. The personally controlled electronic health record (PCEHR) system was launched in July 2012 and, by February 2013, 56 000 Australians had registered for a PCEHR, supported by 1171 health care organisations and 1325 individual practitioners.1 The new electronic Practice Incentives Program payment framework for general practice, introduced this year, requires significantly more sophisticated messaging capability to meet minimum criteria.

Workforce and infrastructure: Annual GP registrar intake will increase to 1200 places in 2014, although primary care training placements for other health disciplines are limited. The rapid escalation in medical student and registrar numbers has stretched GP trainers to the limit, with strong concerns expressed by both the Australian Medical Association and National General Practice Supervisors’ Association.

The GP Super Clinics program has proven controversial, with 29 of 60 Super Clinics funded by the Department of Health and Ageing currently listed as operational.2 Practice infrastructure grants to expand capacity in over 400 existing general practices nationally have been fully subscribed.

Financing and system performance: Little reform has occurred in this area. Budget cuts have reduced general practice quality incentives and MBS mental health payments. Professional bodies have been involved in robust debate about the decreasing real value of Medicare rebates and appropriate funding support for complex comorbidity management. The Improvement Foundation has continued to develop and implement new Australian Primary Care Collaboratives. This year, responsibility for these will transition to the Australian Medicare Local Alliance, maximising local support. The Australian Commission on Safety and Quality in Health Care’s focus on primary care will also commence in earnest.

Collateral change: Change outside the Strategy’s remit has also occurred. The Royal Australian College of General Practitioners (RACGP) released its blueprint for the general practice sector, endorsed by all GP groups through United General Practice Australia in March 2012.3 Much discussion has centred on its overlap with new international models of primary care, particularly the patient-centred medical home (PCMH).4 New national models of general practice that boost capacity and reach are also evolving.5 Last year, the RACGP launched its pilot of clinical indicators to allow practices to benchmark performance in 22 areas of evidence-based practice.

Links with state health initiatives: Late last year, the Department of Health and Ageing released the National Primary Health Care Strategic Framework for comment.6 It presents priority areas (within the context of the Strategy) for the federal and state governments to pursue together. These include development and promotion of innovative “pathways through care” models, collaboration between local health networks and Medicare Locals to examine innovative care coordination for people with complex chronic conditions, promotion of multidisciplinary teams, support for the continued development of GPs with advanced skills, and development of integrated extended-hours clinics. Funding models incentivising safety and quality, a population health focus and reduced hospitalisation are also discussed. Several states have already undertaken transfer of some state-funded primary care functions to non-government organisations and Medicare Locals. All state and territory governments have until June 2013 to deliver their responses to the Framework.

To date, health care consumers will have recognised little tangible change. The general practice workforce in Australia still struggles to meet need, with great variations in access across the country. Depending on location, 3%–15% of Australians delay or avoid seeking general practice care because of cost.7 Many people registered for a PCEHR are awaiting practice management software capability for upload. A few rural Australians, but not those in urban areas, have enjoyed videoconference consultations with a specialist as part of their primary care. Many Medicare Locals are busy transitioning from the Divisions of General Practice from which they evolved. For some communities, this has resulted in reduced service availability; for others, expanded options. While state government response to the Strategy is expected to encourage better care integration between the community and hospital sectors, concrete changes to consumer experience will take time. Timely, safe discharge communication between hospitals and general practice still varies greatly.8

The estimated number of practice nurses has trebled since 2003, but the GP workforce remains stagnant,9 and accurate figures on allied health growth in primary care are impossible to obtain. Without sufficient capable workforce, expansion of primary care capacity and quality is also impossible.

While most other developed countries have moved to “blended” payments for GP services, Australian primary care funding only minimally supplements fee-for-service (FFS) payment. In the United States, the PCMH funding model complements FFS care with bundled payments for prevention and complex chronic disease care, and performance bonuses for quality care deliverables. Significant additional funding to PCMHs is provided by redirecting savings in secondary care, particularly emergency department visits and inappropriate hospital care. In Ontario, Canada, application of the PCMH model has resulted in significantly increased overall practice funding, with FFS now representing about 40% of individual practitioner income.10

Effective e-health in primary care is more about building patient–provider relationships, clinical communication, access and patients’ engagement in their own good health than about implementation and electronic recordkeeping in isolation. Primary care in North America has demonstrated much greater use than Australia of videoconference consultations, email interaction and patient e-tools — largely due to funding and change management support.