Harnessing our collective capability could enable effective, ongoing reform
For over 20 years, the composition, delivery and importance of primary care have been the subject of quickening international reform. In 1993, the United Kingdom government announced a “primary care-led” National Health Service, underpinned by primary care commissioning and general practitioner fundholding, both vehicles to allow local primary care clinicians to influence government purchasing of health services for their community.1 In 2001, New Zealand introduced its primary health organisations, delivering comprehensive primary health services to enrolled populations either directly or through provider members.2 In 2007, the United States described the patient-centered medical home3 — an approach now linked with provider accountability, care analytics, and a focus on population health and the Affordable Care Act, often referred to as ObamaCare. This was signed into US law in March 2010 and aims to expand the affordability, quality and availability of private and public health insurance through consumer protections, regulations, insurance exchanges and other reform.
In Australia, primary care reform has been more timid, with general practice accreditation to support quality improvement, Divisions of General Practice and Medicare Locals tasked with specific local health system improvements, and an open-ended Medicare system expanded to support team care.4
International health care delivery is now challenged and enabled by the changing epidemiology of health and disease (eg, the recent emergence of the Zika virus), the exciting but confronting reality of disruptive technology (technology that displaces or challenges an established technology), rapidly increasing health care costs, and societies that are increasingly experiencing and celebrating the power of the individual. This suggests future health care systems that will be digitally accessible, appropriately responsive, mindful of costs and benefits, and appreciative of the centrality of patient choice and engagement. Our national health reviews of primary care,5 Medicare,6 private health insurance7 and eHealth8 have recently been completed, and 2016 will usher in their policy impact. The need for change is now undeniable. A value co-creation process, where stakeholders and end users share, combine and leverage each other’s resources and abilities from design to implementation, would provide the collaborative, ongoing impetus required for success.9,10
History has taught us that health care reform is not a finite deliverable. It is, ideally, an ongoing, relationship-based team pursuit of excellence in the community delivery and utilisation of health care — a descriptor not often ascribed to current arrangements. Value, like beauty, is often in the eye of the beholder. Communities value affordability, accessibility, personalisation and quality; service deliverers seek quality, patient satisfaction, professional reward and remuneration; and governments merit quality, safety and cost–benefit return.
Understanding and engaging stakeholders, collectively, in creating value is immensely challenging and time consuming, requiring skilled facilitation and focus. It also requires new platforms of engagement, which allow appropriate input, shared vision and governance arrangements that acknowledge, and positively leverage, inevitable reform tension. Alliance contracting — one such platform used in Canterbury, NZ — has delivered significant and ongoing benefits in health and social care. This involves collaboration between community and acute care providers in a region to address complex health and social care problems by taking a “whole-of-system approach to planning and decision making based on what is best for the patient and health system”.11 As this model becomes a NZ-wide approach to regional co-creation, the future focus will be on achieving agreed outcomes that benefit whole communities, rather than the traditional siloed planning, budgeting and delivery. This approach to value creation could provide a useful reform template for Australia.
Consumers of care will be important co-creators of new care models. With about half of health care service and spend estimated to be related to unhealthy lifestyle choice, consumer buy-in has never been so important in delivering care that makes a difference.
While much easier said than done, the experiences of consumers via individuals, organisations or representative groups should be respected and valued at all phases of reform design, testing, implementation and review. Encouraging, supporting and incentivising patients’ engagement in their own care is also fundamental.
Leaders and champions will be essential for success. It is easy to frighten communities regarding the unknown; the more challenging option is to harness change to confront, address and improve the realities of the future. The future for health, as with education and banking, involves the reality of disruptive change that will enable new approaches that build capacity and access, resulting in a shift in traditional methodology. A rapidly reduced national gross domestic product is a current powerful imperative for primary care’s chief funder to require a focus on achieving more with less. A co-creation approach, involving providers and end users as active partners in addressing and responding to this reform driver, would be highly beneficial. Initiatives such as Choosing Wisely12 and the Medicare Benefits Schedule Review6 could benefit from this methodology. But critical to the success of ongoing reform are leaders and champions who understand the reality and complexity of clinical care, can communicate clearly the change drivers, see the opportunity as well as potential difficulty, and lead their organisations and communities as important co-creators in future health care delivery.
Important new stakeholders and influences will arise from public, private and social sectors, as building the value and outputs of care for health consumers becomes the central target. Technology partners are increasingly important, as are those who assist in measuring the impact of health endeavours. Data collection, sharing, meaningful review and quality improvement are just beginning at a systems level, yet partnerships which embrace and enhance these can grow significant value.
Growing experience and confidence with the techniques and benefits of value co-creation will enable a “win more, win more” result, as partners in successful co-creation ventures enlist a growing circle of interested parties, including volunteer groups, local government, the health-focused business community, and social care organisations.
Peering into the primary health care system of the future may be frightening for some, but it can also be exciting for many. Technological advances will allow rural, aged, time-poor and disabled Australians to step beyond the tyranny of distance and engage more actively in their health. Point-of-care testing and community care models will reduce the cost and inconvenience of care. The “burning platform” of the health care budget may even unlock collective innovation and a willingness to change. Health care reform is not linear — there will be unexpected outcomes (both good and bad) and many learning opportunities. Most of all, there may be the opportunity to collectively unite over time to extract maximum value from our health care system for all of us who are so dependent on it.
Provenance: Commissioned; externally peer reviewed.
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