How to strengthen general practice in Australia

It’s hard to believe that Australia’s universal healthcare system, Medicare, is almost forty years old. Over that time, Australians’ health needs have changed significantly. We’ve got an ageing population, and mental illness and chronic disease are on the rise.

GPs’ work is more complex – and Medicare hasn’t kept up.

Our latest report, A new Medicare: Strengthening general practice, calls on Government to overhaul a system that is reaching a mid-life crisis.

Host Kat Clay is joined by the authors of the report, Health Program Director, Peter Breadon, and Visiting Fellow Danielle Romanes, to discuss how to strengthen general practice in Australia.

Transcript

Kat Clay: It’s hard to believe that Australia’s universal healthcare system, Medicare, is almost 40 years old. Over that time, Australians health needs have changed significantly. We’ve got an ageing population and mental illness, and chronic disease are on the rise. GP’s work is more complex, and Medicare hasn’t kept up.

That’s why our latest report, A New Medicare Strengthening General Practice, calls on government to overhaul a system that is reaching a midlife crisis. It shows how Australia can turn the tide of chronic disease, keep more people out of hospital, and make sure people on low incomes can get the help they need, when they need it.

The authors of the report are here to discuss what needs to change, and so we’re joined by Health Program Director Peter Braden and visiting fellow Danielle Romains. Now there have been reports of a GP crisis in Australia. Like many health professionals, GPs are burnt out and there are rumours of a GP shortage.

What’s going on Danielle?

Danielle Romanes: As you highlight these stories about a crisis and general practice and shortages of GPs have made a really big splash in the media this year. It’s certainly true that waiting times are longer and bulk billing rates are lower than they were before the pandemic. These stats reflect a system that’s under real strain, and we know the GPs are really feeling it with rising levels of stress and burnout reported by them in survey.

But when we zoom out just a bit, the facts really don’t support the idea that GP shortages are the root cause of these problems. To be clear, the rural areas in Australia definitely do not have enough GPs. And our report proposes, solutions to that, but at a national level, Australia actually has more GPs than it ever had in the past.

Australia has more GPs than almost all other wealthy countries. And it has more GPs on the way with record numbers of GPs in training now. So, the real drivers of the increasing strain that GPs are feeling come from a rising tide of complex chronic disease. And that’s a burden, as we show that is not evenly spread.

So, since Medicare was founded in 1984, a while back now, there have been really big increases in the proportion of Australians who have multiple chronic diseases. including mental ill health. And this has a big impact. The chronic diseases make up two thirds of the disease burden across Australia now, and they contribute to nearly nine in 10 deaths.

And the burden isn’t evenly spread. So, people on lower incomes are almost twice as likely to have multiple chronic conditions. And that burden isn’t evenly spread. So, people on lower incomes are almost twice as likely to have multiple chronic conditions.

Kat Clay: So, I mean, those are pretty big problems. I probably can guess the answer here, but how are they playing out?

Peter Breadon: Well, the system’s not working well for anyone really. for the GPs, you know, Daniel spoke about how, you know, since Medicare was set up, people have gotten older, people have gotten a lot sicker. And so, the patients walking in the door of the clinic are getting more complex to treat and they’re needing more support to manage their own care.

And more check ins, more advice between appointments. That’s a big burden on GPs, but the system stops them adapting their care to meet those needs. So, since those complex health needs have gotten harder to manage, the average length of a GP visit has stayed stuck at 15 minutes. So, it’s not getting longer.

So, GPs feel they’re racing to keep up and cramming more and more complex work into the same amount of time with very little support. So that’s really what I think is behind a lot of the stress and burnout and people reporting that they feel unsupported by the broader health system as GPs. And for patients, I’m sure a lot of patients listening to this will maybe have felt rushed or that they couldn’t get in as quickly as they’d like.

at one time or another. So, it’s not working well for patients and unlike other countries that have reformed general practice, we’re finding that avoidable hospitalizations, hospitalizations that might be reduced by really high-quality primary care, they’re not going down in Australia like they are overseas.

And in the last few decades, we’ve seen hospital expenditure by Australia on a really explosive rate of growth while funding for. Primary care has remained fairly static. So, for GPs, for patients and for the sustainability of the system, the whole system is reaching a breaking point.

Kat Clay: So, I mean, the system, as you’ve said, is reaching a breaking point, but I mean, what’s stopping change here?

Danielle Romanes: The two factors are keeping that 15-minute appointment with frozen and hand baths. and those are workforce models and funding models. So compared to most other fields in medicine, general practice isn’t much of a team sport. The GPs make up the overwhelming majority of the workforce and they don’t shift tasks to other members of, of the team, the extent that we see in other fields.

And that’s partly because of the nature of general practice, but much of it is really specific to Australia. in other countries, we see much more team-based care in general practice. GPs have far more support staff. So, to provide an example, in Australia for every 10 GPs, there are fewer than three nurses or other clinicians to support them.

While in England, there are 10 supporting clinicians for every 10 GPs. So about triple the support staff. So, GPs have more support in other countries and that enables them to delegate tasks or share, share work like health promotion, minor procedures like ear syringing. Routine checks on chronic disease patients and immunization.

So, workforce is a really big factor here. GPs can’t do more because certainly isn’t enough labour to go around. The other big driver of the problem is the funding model.

Kat Clay: So, I mean, Danielle, one of the issues is obviously the workforce model here, but the other big problem is funding. Can you take us through a little bit of that?

Danielle Romanes: So, the Medicare funding model has changed a bit over the last few decades, and we’ve sort of grafted on new elements. new billing items for chronic disease and a few other changes. But the kind of essentials of the funding model have stayed the same. And those essentials are that GPs will lose income if they share care with another team member.

Some team members won’t be compensated at all. So, there are, workforces like physician assistants who can do much the same. workers, GPs, if it shows with great outcomes or less skilled medical assistants who can do administrative and really basic care on behalf of GPs, they won’t be paid at all. So that’s a big, big deterrent to sharing care.

GPs also lose out on funding if they spend more time with their patients. And that’s because the funding model rewards shorter consults. We say it has a focus on speed really, not need. The other aspect is that the funding model isn’t designed to promote equity or to resolve problems of equity and maldistribution in the system.

So, for hospitals, we build services where patients need them. In primary care, GPs decide where they practice, and then the funding follows them. So, it’s a much more passive approach. That means that GP numbers are higher and rising in wealthy metro areas that are already really quite well serviced. And we’ve really struggled to move GPs into rural areas where there are severe shortages.

Kat Clay: So, I mean, one of the things that was very interesting about your report was talking about, the funding and how it incentivizes shorter appointments. And so, when people come with complex issues or, or things that take longer time, the incentive there is for GPs to get people through as quickly as possible.

So, it’s really interesting that the funding model changes that you propose in the report. Now what I presume is that Australia isn’t, the only country dealing with these issues and with an aging population and rising chronic disease. So, what I’d like to know, what are other countries doing to modernize their health systems and what can we learn from them?

Peter Breadon: You’re right Kat, we’re actually way behind the leading countries in this regard. Almost every sort of wealthy similar system to Australia in terms of health care. Has moved away from this pure fee for service model that we’ve clung on to. Even some of the long-term holdouts, like some of the provinces in Canada, like British Columbia that still have mostly fee for service are making the switch next year.

So, we’re a long way behind. The good news is we can learn from all of those other countries. And as Danielle has touched on, and you touched on it in your question, it just makes a lot of sense not to pay the same amount of money for taking care of every patient. Some patients are much more complex. And we know that factors like clinical complexity.

So how many diseases you have factors like age and also disadvantaged. They all mean that GPs have to spend longer to help keep people healthy, but our funding model ignores all of that. Now, as I say, most of the countries around the world that we can learn from have changed. They’ve started to adapt funding.

So, it better matches need. So, we can learn from them. And the other thing that other countries have done was really take assertive action to try and broaden out and diversify that care team. As Daniel described, it’s much more of a team sport in other countries with maybe pharmacists, medical assistants doing administrative work, psychologists dealing with the rising burden of mental health concerns in the community.

Other governments have started to inject these workers directly into general practice so they can work within general practice alongside GPs. And provide more of the care that people need in one place. These countries like the UK and like New Zealand, paying the salaries for these workers to make sure that you can accelerate change, and really rapidly expand access to, to care.

And we propose doing that in the areas that are most underserved, where people are missing out today.

Kat Clay: Yeah. One of the more interesting programs that you highlight in your report was the NUCCA model from Alaska. I found that really interesting, how it’s kind of rating, radiating out from the centre using, you know, a multidisciplinary team.

And you have a great diagram in your report showing, you know, the potential way that teams could be set up in Australia so that you could serve kind of, high needs and low needs patients.

Peter Breadon: You’re right, Kat. It’s a very inspiring model. It shows how a small core clinical team called a teamlet can be comprised of a GP that’s supported by one, two other clinicians.

It might be medical assistant doing administrative work, might be a nurse or a nurse practitioner, or in Australia, an Aboriginal health worker. And this small team of two, three or four really work closely together every day and they’ll provide continuity and ongoing care for a group of patients. But within the clinic, there’ll be supported by this broader team.

And we’re proposing that the government invest in injecting a thousand new workers into those both teamlets and the broader teams, bringing those disciplines into primary care. So, it might be pharmacists to check on people’s medicine and help them with that. It might be physiotherapists to deal with musculoskeletal issues.

Or, as I mentioned before, it might be psychologists to help with the, the growing burden of care. Mental illness. So, I think it is a really inspiring model and a great one to look at.

Danielle Romanes: And so just to flesh that out a little for our listeners, it’s really worth highlighting just how transformative that NUCCA model has been for patients, living in Alaska who were, you know, disproportionately indigenous and, and facing very poor health outcomes compared to the rest of the country.

So, Don Berwick, who is a leading luminary in healthcare, I’m sure many of you are familiar with his name, has referred to the NUCCA model as. Probably the best example of primary care transformation in the United States, but, but probably the world and the results really speak for themselves. The new careers reduced demand for hospital care by 30 to 60 percent with big, big reductions in binge drinking, suicide, stroke.

Death from heart disease and cancer, and big improvements in infant mortality, child asthma, and immunisation rates.

Kat Clay: So, Danielle, those outcomes are fantastic, but I mean, in Australia, attempts to reform primary care have fizzled in the past. I mean, one only needs to think of the Healthcare Homes Trial, which didn’t deliver on the promised outcomes.

Do these failed attempts at reform spell doom for future attempts?

Danielle Romanes: Okay, it’s certainly easy to feel despondent after the Health Care Homes trial, which trailed a new funding model for general practice. So, as you mentioned, it was not a success, half the general practices dropped out, and a third of patients before it ended.

And the evaluation found it failed to deliver on really any of its key objectives, with no improvement in health outcomes. or patient satisfaction, or avoidable healthcare use or costs. But Healthcare Homes isn’t the only attempt to improve general practice in Australia. We’ve actually had four tries over the last three decades, more pilots than Qantas, as we say in the report.

I’m pleased to say that with the exception of Healthcare Homes, the other trials actually steadily improved over time as, as implementers learned and refined models. The last trial before Healthcare Homes, the Diabetes Care Project, and we’re on 200 practices and almost 8, 000 patients in just six months, which is actually one of the fastest uptakes of a large-scale reform program of anywhere in the world at the time of the evaluation.

And it delivered statistically significant improvements in health and mental health, particularly for the people at highest risk of long-term complications. And it’s easy to get kind of dry about these things. And we talk about statistical significance and the like, but for those people that meant a reduced risk.

Of amputations of blindness. of catastrophic heart failure. It’s really hard to understate how important and how transformative those improvements are and how important it is that we, you know, we continue to pursue them. And so, what the diabetes project and other prior pilots show is that it is possible to improve general practice and deliver better outcomes for patients.

But to do so, we need to get the design of these trials right, we need to get the sector on board with the change, and really crucially, we need to have a long-term scaling pathway that enables us to go from the short-term pilot to

Kat Clay: permanent change. So, I mean, like anyone, we want to get it right if we implement reform.

What can governments learn from these prior experiences?

Danielle Romanes: So, to avoid another dead-end trial, in this report, we call on government to commit to a multi term strategy. Changes to funding, regulation, governance. So first we say government needs to spend a good 18 months in planning, consultation, and detailed design of the model.

They need to develop a compelling vision of what general practice should look like. That’s backed by evidence, is implementable, and it has. The sector’s support, the workforce’s support. Government needs to make a long-term commitment to expanding that vision from early adopters across the system, working with the willing, with a credible pathway and multiple checkpoints to evaluate and adjust the model over time.

It needs to support the, the frontline to turn vision into reality, starting with the general practices that are ready to change. So, this means giving participating practices the help they need to adapt, the way they work. including funding, expert advice, data analysis, and leadership training for GPs.

Finally, it needs to invest in building up the capability of PHMs in the Department of Health to support and manage system performance. Our prior reviews of both the PHNs and the department have highlighted shortcomings in this space. This is well worth the while. So, taxpayers make a 10 billion annual investment in general practice.

If we can better manage the system, we can get a much better return on that spend.

Kat Clay: So, Peter, I mean, change isn’t usually cheap. Will these recommendations that you’re making eat into an already thin budget?

Peter Breadon: Well Kat, I’ve got some great and maybe surprising news for you. The money is already there. The government in their last budget committed 250 million a year to fix general practice.

And we’ve designed our report with this in mind. So, all of our recommendations can be funded within that budget. That’s already been set aside. And that means injecting those thousand new workers in the areas of greatest need, as I spoke about, it would cover introducing a new funding model that rewards and supports team-based care.

and shifts money so that it follows the patients with the greatest needs. And it will also fund the change support that Danielle spoke about to really help clinics do the difficult and challenging change to practices that is involved in shifting to a more team-based model. And there’s one other important recommendation we haven’t touched on so far.

There are parts of Australia that where there really aren’t enough GPs to go around. And in those areas, a new funding model won’t fix the problem. Instead, state governments and Commonwealth governments have to come together to pay salaries and create roles and support existing practices, or build them from scratch, or put them into a rural hospital setting to make sure that rural people get the care they need.

So that’s the final recommendation in our report is that in those areas that are underserved, governments have to come together. To create the supply of care.

Kat Clay: Thank you so much, both Peter and Danielle for being on the podcast today to talk about the reform needed to Medicare and general practice in Australia, and hopefully bring about greater outcomes for all of us.

If you’d like to read this report, please do go to our website. It’s available for free at grattan.edu.au. And likewise, if you’d like to talk to us about this report, please chat to us on social media at Gratton Inst and all other channels at Gratton Institute. We’re in the middle of our Christmas giving campaign, and we’d really love your support financially to keep both this podcast and Gratton’s research going.

If you would like to donate to Grattan’s work, please visit grattan.edu.au. We always appreciate your support as always, please do take care. And thanks so much for listening.