Six lessons for Australia from decades of general practice reform - Grattan Institute

News of a crisis in general practice dominated the headlines last year. Just before Christmas, the federal Taskforce charged with fixing it wrapped up. They had just six months to come up with a plan for solving a crisis that has deep structural roots.

As we showed in our report, A New Medicare, Australia’s general practice system was designed for an earlier era and hasn’t been updated in response to the rise of chronic disease. GP work has grown more complex, but the model for general practice has changed little.

Compared to peers overseas, Australia’s GPs have far less support from a broader care team and have to pack more and more care into 15-minute appointments. Any attempt to change is hampered by fee-for-service funding, which promotes churn, blocks team care, and which almost all other wealthy countries have moved away from.

There are clinics in Australia where multidisciplinary teams and flexible funding support high quality chronic disease care. In particular, this is common in Aboriginal Community Controlled Health Services and in community health providers. But reform is needed to make these models viable in clinics across the country.

The Taskforce’s final communique was promising. It supports key recommendations in our report, such as multidisciplinary team care, a blended funding model, and a bigger role for Primary Health Networks.

The communique sets out broad directions for general practice. The question now is how to make those changes, so that this time they stick. To do so, the Government must learn from decades of stalled attempts to shift the system.

Australia has failed to make reform stick

Four national pilots, or trials, for general practice reform have been run over the past four decades (see Table 1). None have stuck.

The Howard Government ran two iterations of trials to modernise care for chronic disease patients. The 1990’s Coordinated Care Trials were probably the most ambitious Australia has run – pooling funding at both state and federal level to flexibly fund coordinated chronic disease care. Most trial objectives weren’t achieved, but many things were learnt.

The outcomes of the next version of the Coordinated Care Trials were better on all counts: improved patient self-reported health, lower hospital demand, and costs trending in the right direction.

Table: More pilots than Qantas – what have we learned from three decades of primary care reform trials?

TrialImplementation lessons
Coordinated Care Trials I (1997 to 1999)

• Trialed models of coordinated care to improve the health of people with multiple service needs within existing resources.
• Randomised controlled trial (RCT)
• 16,000 patients
• Many trial sites ran for only 1 year
• Trialed models of care coordination, care planning, and funds pooling
• Over-funding patients with only mild need increases cost, with no benefit
• Rushed timelines for design and implementation reduce impact
• Funding reform alone is not enough to drive behaviour change
Coordinated Care Trials II (2002 to 2005)

• Trialed models of coordinated care to improve the health of people with multiple service needs within existing resources.
• RCT design at some sites
• 1,175 patients
• Trial sites ran for 21-to-29 months
• Trialed models of care coordination, care planning, and funds pooling
• Implementation is very difficult at both a system and practice level
• Poor systems and management do not self-correct, they deteriorate
• Funding reform and workforce recruitment are critical to encourage and enable care coordination
Diabetes Care Project (2011 to 2014)

• Trialed models of primary health care delivery
• RCT (1 control, 2 intervention groups)
• 5,651 patients completed (all diabetics)
• Minimal participant attrition (16%)
• Trial sites ran for 18-to-22 months
• Practices will use new tools and supports if they are given incentives to do so
• Funding reform is essential, and blended models with well-designed performance payments can work
• Addressing unmet need may improve outcomes but cost more
Health Care Homes (2012 to 2021)

• Trialed the ‘health care home’ concept to manage and coordinate care for patients with complex and chronic conditions.
• Non-experimental (lower quality) design
• 9,000 patients
• Very high attrition (53% of practices)
• Trial sites were to run for 2 years, but were extended after enrolment delays
• GPs need a clear vision with compelling evidence to buy in to the model
• Practices need clear guidance and sufficient implementation support
• Staged implementation is needed to close practice capability gaps
• Simplistic funding models expose practices to excessive costs
Sources: Esterman and Ben-Tovim (2002),ix Department of Health and Ageing (2007),x Department of Health and Aged Care (2015),xi Fountaine and Bennett (2016),xii and Department of Health and Aged Care (2022a).xiii

The third trial, the Gillard Government’s Diabetes Care Project, was perhaps the most successful. It trialled blended funding adjusted for patient need, among other changes. There were significant improvements in patient health for those in greatest need. Costs and hospital demand were again trending in a very promising direction.

What these three trials had in common was high-quality experimental design, large-scale participation, and a trajectory of learning from, and improving on, what came before.

By contrast, the most recent trial, Health Care Homes, failed to lock in earlier gains and build upon success. Instead it had a poorer design, with less sector uptake and worse outcomes, than its predecessors. The final evaluation showed it had achieved none of its objectives.

We must break this cycle. To make the next reform stick, governments must learn six lessons from the previous trials: show where we’re going, plan the journey, bring people along, help clinics change, provide certainty, and support shared leadership.

1. Show where we’re going

First, Federal Health Minister Mark Butler will need to invest much more time upfront in engaging clinicians and the community in a shared vision for ‘a new Medicare’. The GP sector have been bruised by Health Care Homes, the pandemic, and the long Medicare rebate freeze.

GPs can’t get on board without first being shown where they and the system are going – a finding from the Health Care Homes trials. Even GPs who don’t need much convincing will struggle to explain the model to their patients without a clear vision.

GPs and patients need to see what a future model will look like, and what’s in it for them.

2. Plan the journey

Second, sufficient planning and communication are needed to get the details right and build support.

It is hard to overstate the complexity of general practice and the investment needed to build and iterate a new, better model. As previous evaluations have found, poor trial design does not self-correct: it deteriorates.

3. Bring people along

Thrid, deep engagement with patients, carers, clinicians, and practice-owners will be essential for success. And as well as consulting locally, Government should draw on international expertise.

Australia is one of the last wealthy countries to reform its general practice workforce and funding models.

This gives us a last-mover advantage. The Federal Government should use it, establishing an independent expert advisory committee of people who have worked on and learned the lessons from similar reforms overseas.

4. Help clinics change

Fourth, front-line implementation support is needed to turn the vision into reality, starting with general practices that are ready for change.

Australia’s ‘fee-for-service’ funding model and workforce regulations are a profound barrier to team-based care. This means Australia has less diverse teams compared to overseas, and clinicians don’t get to work to the their full skill level.

To get the most out of multidiscplinary teams requires new ways of working – simply slotting a new workforce into a practice won’t work.

Most practices are small and change is hard for any organisation. New models of care go beyond simple tweaks to processes, and it’s easy to underestimate how hard it is. Strong support will be needed.

Practices keen to participate should be given generous change-support funding (a Health Care Home lesson), support from expert facilitators in Primary Health Networks (PHNs), and a five percent funding boost to help cover data capture and change costs. These practices should also get priority access to the $220 million of general practice infrastructure grants announced by the Federal Government.

5. Provide certainty with long-term commitment

Fifth, short-term funding cycles and commitments have repeatedly undermined any hope for system-wide reform.

Past trials have lasted only two years at most. This is problematic because chronic disease health gains take time to eventuate, and it doesn’t make good business sense for clinics to disrupt how they work, only for support to be withdrawn soon after.

General practices need long-term commitment to turn a new model into widespread practice. Government should stagger implementation of a new model, rolling it out over the next five years, carefully reviewing and refining along the way.

6. Shared leadership

Finally, all the players need to get in the reform game.

Groups representing different health professions have often been at loggerheads. Doctors’ groups have been accused of blocking reform while hoarding patients and funding. Other groups that call for shared care have been accused of jeopardising patient safety and fragmenting care. Meanwhile, the GPs’ professional body has dismissed Primary Health Networks (PHNs), the regional bodies responsible for improving the system. And many GPs say that both the PHNs and the Deparment of Health don’t understand how their businesses work.

In reality, all these groups all have important roles to play. Particuarly in Australia’s extremely fragmented healthcare system, they need to overcome their differences and get behind a shared plan.

The Strengthening Medicare Taskforce made great strides. In just six meetings over six months, all the key players agreed on broad directions for change.

But a lot more work is needed to overcome deep divides and distrust, and to hammer out a workable plan.

Minister Butler brought key groups to the table, but now they can’t just retreat to lobbying for narrow interersts. Instead, they should push for an ongoing reform process where they can join the discussion about how to reshape the system, and mobilise their membership to be a part of it.

There is hope

It’s easy to feel like real health reform might never arrive in Australia. But there are reasons to be hopeful.

While the Health Care Homes debacle was disappointing, the trials that preceded it show it is possible to reform general practice, reduce hospital demand, and improve the lives of the millions of Australians who live with chronic disease. And many other countries have already made the changes we need, showing how it can be done.

By learning from our past, and from leading practice overseas, Australia can make a new Medicare that can tackle the 21st Century challenge of chronic disease.

Lauren Richardson

Senior Associate
Lauren has held senior policy and operational positions in government, and is Teaching Associate at Monash University, School of Public Health and Preventative Medicine. She is currently completing a dual Master of Public Health/Global Health at the University of New South Wales and is an active member of the Political Economy of Health special interest group with the Public Health Association of Australia.

Peter Breadon

Health and Aged Care Program Director
Peter Breadon is the Health and Aged Care Program Director at Grattan Institute. He has worked in a wide range of senior policy and operational roles in government, most recently as Deputy Secretary of Reform and Planning at the Victorian Department of Health.

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