Primary Care Reform in Australia: general practice leading the way Professor Claire Jackson RACGP President Professor of General Practice and Primary Health Care and Head of Discipline, University of Qld School of Medicine

Australian healthcare system (a snapshot !) Medicare: universal health insurance (1.5% taxable income) Strong public / private mix High international benchmarks in longevity, chronic disease outcomes, survival rates, access, satisfaction, cost ‘Closing the gap’ – our national disgrace Dual state and Commonwealth funding arrangements, their gaps, inefficiency and duplication a strong current reform focus

Australian primary healthcare: context General practice ( our PCMH!) o 27,000 GPs (predominantly FFS, SIP, PIP) o Over 125 million consultations / yr, 80% ‘bulkbilled’ o see 83% population annually, big practices o holistic, ‘cradle to grave’ model, team focus Community health (state-funded) NGOs – predominantly aged care Aboriginal community-controlled health services

Australian primary healthcare: key national players Royal Australian College of General Practitioners Australian Medical Association Rural Doctors Association Australia Australian General Practice Network, representing 100 divisions of GP nationally General Practice Registrars Australia Royal College of Nursing, Australian Nursing Federation Pharmacy Guild

Australian primary healthcare – what does the future hold ?  2010 National Health and Hospitals Reform Commission report Australia’s First National Primary Care Strategy GP Superclinic roll out (34 settings) Legislation re personally controlled e-health records MBS / PBS access for nurse practitioners and midwives PM’s ‘Big Bang’: ‘National Health and Hospitals Network for Australia’s future’ (1 and 2, COAG, 2010 Budget) A major national health care reform agenda strongly focussed on primary care

The National Health and Hospital Reform Commission  Embed prevention and early intervention into every aspect of our health system and our lives, particularly for children and young people  Connect and integrate health and aged care services for people over the course of their lives  Strengthen primary healthcare services... building on the vital role of general practice...creating a platform for comprehensive care bringing together health promotion, early detection and intervention, and management of acute / chronic conditions  Integrating multidisciplinary primary healthcare services with Commonwealth oversight  Establishing comprehensive primary healthcare centres and services  Voluntary enrolment with a ‘healthcare home’

The National Health and Hospital Reform Commission  Expand specialist services / palliative care support / hospitals in the community  Establishing PHC Organisations to support population health care planning and coordination  Create a comprehensive primary healthcare platform under Medicare (including state-health services)  Mix of funding models  Reshaping the Medicare Benefits Schedule (MBS) to reflect scope of services to be included, competency and scope of practice, driven by evidence and ‘continuity and integration of care through collaborative team model of care  Fostering clinical leadership and governance and e-health  New framework for flexible, competency-based IPE and dedicated $ for clinical placements and NCETA

Australian primary healthcare – what does the future hold ? 2011  Council Of Australian Governments (COAG) national health reform heads of agreement  Creation of Local Hospital Networks (LHNs) as direct recipients of Commonwealth and state funds  Strong performance accountability, measurement and public reporting  Medicare Locals (MLs): primary healthcare organisations responsible for coordinating and better integrating PHC services in their local region, improving access, preventive health and addressing care gaps (60)  Strong articulation between MLs and LHNs  Ongoing increase in GP training places, rural only increase for other specialties

So, what does the future hold? A major national healthcare reform agenda strongly focussed on primary healthcare

Key drivers Chronic disease prevention and effective management Disaster fears (tsunamis, floods, fires) Cost containment and ‘efficient costs’ Building quality Improved access especially for marginal groups International approaches Public pressure

Where does primary care fit into the Brave New World ? FRONT AND CENTRE Limited only by its clarity of o purpose o planning o imagination o infrastructure

The primary healthcare reform environment Building a system from a sector Increasing relevance, funding and accountability Changing dual system governance structure Improving integration with acute and aged care Building effective teamwork across disciplines Advanced and enhanced care opportunities within the community Focus on regional integration of care, e-health, workforce growth, infrastructure, and financing and system performance

GP Superclinics ( ) GP Superclinic: a comprehensive set of primary care services led by a GP within an academic infrastructure Mixed reaction from the profession Key to the future is the specialist service enabler, breadth of service and efficiency New initiatives include infrastructure support for conventional general practice to achieve this

What is the focus for our sector? Building workforce, infrastructure, practice teams, training and networks to deliver the futuristic healthcare service our country is seeking Looking at how our holistic model of care fits with the future, scoping opportunities and threats and moving forward with high quality, comprehensive primary care Training – registrars, general practitioners with a special interest (GPwSI) – building capacity to deliver efficient, accessible, comprehensive community care Effective integration of a multitude of providers, services and organisations under the Primary Healthcare Organisations/Medicare Locals

Watch this space ! A lot is happening Down Under which offers opportunities for international collaboration and policy development Significant need for high quality research to inform the new arrangements Concerns re governments’ track record in delivering such large scale reform and small budgets from Medicare Locals But … first ever serious focus on funding, organisation and accountability around integrated care delivery Recognition than improving primary care capacity and access a life line to retaining high quality, affordable healthcare in our country

Some new models: UQ’s Primary Care Amplification Model (PCAM) Pilot: Inala Primary Care Creates a ‘beacon’ practice in an area which acts to support and extend the capacity of primary care in the area, and better integrate service delivery locally between general practice, specialist services and other state-funded care Accomplished via the establishment of a general practice ‘mustering point’ for an expanded scope of practice for primary care in areas of population need, service innovation, teaching, ( u/g and p/g) and relevant local clinical research.

UQ’s Primary Care Amplification Model (PCAM) Central to PCAM is the provision of the core elements of general practice and primary care – first contact, continuous, comprehensive and coordinated care provided to populations undifferentiated by gender, disease, or organ system The Amplification Model features four additional key characteristics: – an ethos of supporting primary care within and external to the practice – an expanded clinical model of care; – a governance approach that meets the specific needs of the community it serves – and a technical and physical infrastructure to deliver the expanded scope of practice. It is these characteristics that enable a ‘beacon’ practice to realise its potential

The Primary Care Amplification Model Ethos Physical infrastructure to support local practices increase their scope of practice Undergraduate and postgraduate teaching Focus on supporting local practices in increasing the scope of primary care delivery Advanced skill development Clinically relevant research/audit activity Culture of Continuous Quality Improvement

The Primary Care Amplification Model Clinical Model of Care Well-integrated primary/secondary and multi-disciplinary team care onsite Integrated clinical share-care protocols outside the practice Comprehensive chronic disease management with a strong patient focus on site Preventative care After-hours provision for patients Electronic clinical information sharing

The Primary Care Amplification Model Governance Integrated inter-organisational governance arrangements Commitment to local service innovation Provisioned planning ‘down-time’

The Primary Care Amplification Model Infrastructure Comprehensive infrastructure within a single location MBS Billing Focus on access and affordability for local population Local population health focus

The Primary Care Amplification Model Outcomes Has made a difference to local patients / community / state- funded health care by building the capacity of primary care around it to deliver expanded services – in the first instance in the area of Complex Diabetes Management The AAAGP endorsed Superclinic model and prototype for the 3 UQ GP Superclinics IPC awarded RACGP Qld Practice of the Year (2009) and has the support of local general practices and DGP in piloting this new and evolving role in the primary care landscape

The Primary Care Amplification Model Complex Diabetes Service Subjects Patients from surrounding 21 postcodes referred to Princess Alexandra Hospital Dept of Diabetes and Endocrinology and whose GPs consent to care via the new model Location Managed at Inala Primary Care

The Primary Care Amplification Model Complex Diabetes Service Intervention DE Case manager screens patients and arranges appropriate Clinic Day review according to need – eg podiatry, diabetes educator, doctor (all). Retinal screening On Clinic morning, patients reviewed by the “Clinical Fellow”, an advanced- skilled GP trained via the UQ DGP’s online MMed (GP), who co-consults with the specialist Endocrinologist and the patient to develop a management approach Case manager follows up patient with phone contact as appropriate to support their participation in the management plan and self management program Variety of education opportunities for local GPs via IPC and for Qld GPs via collaboration with a number of Divisions of General Practice via CHIC

What patients are we dealing with? ICDMS (n=169) Age (yr) mean61.3 ± 12.8 Female (%)50.3% ATSIC5.4% Born in Australia47% Education ≥ Yr % BMI (kg/m2) mean33.3 ± 7.8 Mean duration of DM14 years microalbuminuria50% Stage III kidney disease25% Nerve damage32.5% At risk foot45.4% Eye disease20% IHDx29.6% On insulin49.7%

Glycaemic control for newly referred patients with T2DM at baseline and 12 months at the Brisbane South Complex Diabetes Service (BSCDS)(n=99) and Princess Alexandra Hospital (PAH)(n=67). Baseline12 months BSCDSPAHBSCDSPAH HbA1c (mean ± SD)9.0±2.08.3±1.97.6±1.78.1±1.8 % achieving HbA1c ≤ 7% 14.1 (14)28.4 (19)45.5 (45)32.8 (22)

12 Month Data – Intervention Group Baseline (n=97) 6 months (n=97) 12 months (n=97) Paired t test baseline vs 12 months p value HbA1c (%)8.4 ± ± ± Weight (kg)91.3 ± ± ± BP-sys (mmHg)130 ± ± ± 16.4 BP-dia (mmHg)72.8 ± ± ± Chol (mmol/l)4.2 ± ± ± LDL (mmol/l)2.3 ± ± ± early data suggests the benefits are sustained at 12 months

Why does it work ? Take from ‘The Big Losers’ The Service Accessible, welcoming, team-based The Team The relationship of the team members with patients enabled: Patients' to feel that the team really understood their problems, That they could "talk openly about even little issues" with team members, Patients treated as a person and not a number, Patients felt comfortable returning for appointments, and once referred back to their GPs could also contact the service if they needed additional input or advice. Most importantly, patients liked seeing the same team members

Why does it work ? Take from ‘The Big Losers’ Implications The team improved patients' knowledge and understanding of type 2 diabetes, moved some patients from denial to accepting they had diabetes significant to engage patients in their own health care. Team builds patients' confidence to effectively manage diabetes in an on-going

The future is not a result of choices among alternative paths offered by the present, but a place that is created – created first in the mind and will, created next in activity. The future is not some place we are going to, but one we are creating. The paths are not to be found, but made, and the activity of making them, changes both the maker and the destination ‘ John Schaar, futurist