Take the initiative to link hospital and primary care

by Stephen Duckett

Published by Queensland Government: Board Communique, Monday 30 March

Health costs are increasing in real terms per capita putting pressure on state budgets. The budget screws are tightening and can be expected to tighten more.

The standard approaches to tighter budgets – consolidation, Lean and other efficiency strategies – have been tried and need to continue, particularly through whole of organisation change rather than project by project. Unfortunately, our thinking is often constrained by barriers created by different funding streams. Health services, across primary, secondary and tertiary sectors, need to develop different ways to bring their respective resources together for more effective health outcomes for their communities and to ease budget pressures.

A big shift is underway in primary care which provides some opportunities for hospitals and health services. On 30 June the 61 Medicare Locals across Australia will be replaced by around 30 ‘Primary Health Networks’ (PHNs). Published documentation suggests that the roles of PHNs will suffer from the same vagueness that characterised their predecessors, but there is certainly an expectation that they will work collaboratively with the local Districts.

The vagueness provides an opportunity. Districts can fill the vacuum working with the local PHN to shape its priorities.

I sit on the Board of a Medicare Local and we hear endless stories about problems GPs (and other primary care providers) have connecting with the local hospital. We hear about discharge planning and failures to communicate speedily with GPs, about how bad it is making contact for out-patient referrals, and about losing patients into a specialist out-patient black hole. And that the only way to get specialist advice is via a referral.

No doubt hospital staff have a similar list of problems such as the time taken to arrange adequate home support to facilitate discharge.

So what needs to be done? First, there needs to be a supportive attitude on both sides. To recount a personal example, our Medicare Local was charged with developing a new funding formula for after-hours GP care. Our working party on this topic included GPs and the head of the Emergency Department (ED) in a local hospital. The state health department gave us access to (de-identified) data about who uses EDs and when. They also seconded someone to the project to analyse the data. We designed the funding formula to help reduce demand on hospital EDs. The moral of that story is that the Medicare Local accepted that the hospital’s problem (too many people presenting to EDs) was also a problem that primary care should own.

It was facilitated by good local relationships and the hospital allocating the time of one of its senior staff to work on the issue. The new funding formula increased availability of after-hours care, including in parts of the Medicare Local area which previously had no practices open after hours.

Second, both parties need to recognise there is a mutual interest in finding mutual benefit and that the relationship is about partners helping each other. It’s not a one-way street in either direction. In the after-hours project, GPs got better remuneration to work in unsociable hours and the hospital (hopefully) got reduced demand.

Third, it’s about incremental steps. All the relationship problems between primary care and hospitals won’t be fixed in the first meeting. Trust needs to be built, success needs to be demonstrated.

Fourth, it’s about pooling resources and expertise. This might be on working parties (as in our after-hours example) or joint funding specific initiatives.

Fifth, planning should be evidence-based and data-driven.

The opportunities are great. Queensland projects have already demonstrated that engaging GPs can help clean up long waiting times for out-patient bookings. Improving referral paths has also shown to benefit hospitals, GPs and patients.

So what should boards do?

  1. Expect management to have a clear engagement plan for working with PHN(s), including how they plan to be involved in PHN project governance.
  2. Expect management to have identified specific priorities where joint working with the PHN might improve hospital efficiency, access or outcomes.
  3. Expect management to promote a culture of valuing and supporting primary care.
  4. Authorise management to share data, personnel and other resources to help the PHN on mutual projects.
  5. Devote their meeting time to reviewing strategic issues about engaging with primary care, and the PHN specifically.
  6. Endorse metrics to measure progress in improving the primary care- hospital interface
  7. Hold management to account on those metrics.