Changes to the delivery of primary health care in Australia are being mooted, with support for a new multidisciplinary system potentially expanding the role of nurses and putting them right at the front line of care. What will this new system offer the public and how will nurses be involved? Australia's hospital-centric system has had its day, according to health experts, as workforce shortages and an escalating crisis in the nation's hospitals underscore the systems' inability to cope with demand.
Reformers say broad changes to our illness-focused approach to health care are needed, with a major emphasis on shifting to a system where health promotion and prevention take priority, and where the current monopoly on primary health care delivery by doctors is replaced by multidisciplinary health care teams. An emphasis on health promotion and illness prevention will be welcome news to nurses, whose practice has long embraced the delivery of holistic and 'pure' primary health care where possible. (OECD, 2004)
'Everybody, particularly nurses, knows that we are struggling to maintain a quality hospital system in Australia, but demand outstrips our workforce and bed capacity, and yet we have more hospital beds per capita than any other country in the Western world. Formed in 2003, the alliance has subsequently lobbied governments in an attempt to ensure clinicians and consumers are part of the process of reform. (White, 2004 p. 47-68) The recent Council of Australian Governments (COAG) meeting offered the most promising sign yet that reform is at hand, making a commitment to increase the health system's focus on prevention and health promotion; improve the integration of the health care system; and simplify access to care services for older people, people with disabilities and people leaving hospital. (Condon, 2001)
The alliance has made it clear to governments at all levels that Australia's focus on hospitals and the management of acute illness is a flawed approach, and the nation should be looking to UK and New Zealand models for more effective, equitable, primary care. There are two main problems with the system of primary care in Australia, (Podger, 2006) it is overwhelmingly skewed toward care from just one group of health professionals -- doctors, and the way it is funded makes it inequitable and increasingly unaffordable for lower income Australians who may not be able to afford the gap between their GP's bill and the Medicare rebate.
The private for-profit medical service means outcomes are very much dependent on personal and financial circumstances. If you can afford to pay the co-payment (the cost of the consultation above the Medicare rebate), you might be okay, but poorer people (even those who can access bulk billing doctors) are disadvantaged. It also puts pressure on the medical practitioner to recoup the funds through generating a large volume of patients. This means a lot of six-minute consultations, which don't offer much in the way of preventative or holistic primary care.
A centre such as a primary health organisation (PHO), employing a range of health care professionals -- nurses, doctors, allied health professionals, counselors, dieticians, and psychologists, can provide a much more holistic and effective form of primary health care than a solo GP. (Craven, 2005) Clinicians (including doctors, nurses and allied health practitioners) and health policy experts and economists all seem to agree: the current system is in dire need of reform. In recognition of these concerns, and in the lead up to the federal election, the ANF is lobbying the government for changes to the health system in several key areas. These include overall reform of the health system, strengthening Medicare, reviewing the public funds currently dedicated to the private health insurance rebate, and improving access to dental health services.
Why Reform Is Needed
According to health experts, the health system in Australia is 'disturbingly dysfunctional', with the current funding arrangements requiring urgent reform. (Si D, 2007 p, 453-457)
Clinicians and bureaucrats all complain emergency departments in Australian hospitals are over-crowded; large numbers of adverse events are compromising patient safety in public hospitals; primary health care is increasingly becoming a 'user-pays' transaction for all but the very poor; Indigenous health outcomes are worsening; mental health services are unable to meet demand; dental health is not included in general health funding; and the private sector is in receipt of considerable amounts of public money, which critics say would be more effective, and more efficient, in the public system.
While the Federal Government is responsible for the overall distribution of a health budget equivalent to $30 billion, the bulk of this money is administered by the various state governments for provision of hospital- and community-based care. (Bourke, 2004 p. 181-186) Payment for primary care services, specialist outpatient services and drags are administered directly by the federal government via the Medicare Benefits Fund and Pharmaceutical Benefits Services. Both are uncapped and have rising costs versus the domestic Consumer Price Index. (Ricketts, 2005 p.42-48) This separation in funding between the state and federal health system has led to significant cost shifting within the Australian healthcare system.
Preventative And Primary Health
Despite the immediate focus on hospitals, Labor's health plan shows increased emphasis on primary health care with the development of a national preventive health strategy. A move away from the so-called 'six minute' consultations with GPs in primary care to more comprehensive preventative health care, including better chronic disease management of diabetes, cardiovascular disease and asthma. GPs will be offered incentives to practice quality preventative health care, including health checks for children before they start school. Obesity will be a national priority area.
A $220 million initiative will see GP super clinics set up in local communities as one stop shops for people to access doctors, nurses, specialists and allied health professionals such as podiatrists, dieticians and physiotherapists. (Si D, 2007 p. 453-457) Despite the first super clinics announced during the election campaign in marginal seats, federal Labor maintains they will be rolled out in rural and regional areas and in areas where people have been unable to access health services due to workforce shortages. Centre for Policy Development (CPD) chair and health bureaucrat John Menadue says Labor's general practice super clinics have the makings of a "major health redesign of health care in Australia". "All the international evidence is that a health system oriented toward primary care achieves better health outcomes, lower rates of mortality and greater equity than a health system centered on hospitals." (Doggett, 2007)
Nurse practitioners now numbering about 300 in Australia have been held back in their role in particular in prescribing, ordering diagnostics and referral to specialists because they cannot access the pharmaceutical benefits scheme (PBS) and Medicare. Australian nurses are aware that the UK benefits from a stronger policy framework in the area of nursing and programmes such as the Clinical Effectiveness Initiatives by the NHS Executive and the Royal College of Nursing appear likely to provide motivation and facilitation of evidence-based practice within the Australian nursing profession (Regan 1998 p, 244-250). When discussing the utility of the primary healthcare approach, rural health practitioners point out the inherent differences between rural and metropolitan healthcare culture. In Australia, rural GPs face greater time pressures than their urban colleagues and have fewer opportunities for participating in multi-disciplinary teams. However, in many cases the opportunities for inter-sect oral collaboration are enhanced in rural settings.
The impact of primary care in clinical settings also depends on the way that information is presented to primary healthcare practitioners. It cannot be assumed that the simple inclusion of strategies aimed at changing clinical behaviour will be effective. For example, work on GP prescribing suggests that an emphasis on lack of therapeutic effectiveness is less likely to change GPs' behaviour than information about risk to individual patients (Butler et al. 1998 p, 637-642).
Rather than teaching all primary care practitioners literature searching and critical appraisal skills, there is a need for systems which allow rapid access to credible summaries of evidence. Furthermore, reliance on the passive diffusion of information to keep primary care practitioners' knowledge up to date has little chance of success in an environment in which about two million articles on medical issues are published annually. This has prompted interest in both the development of rapid-access information sources and in educating GPs and other primary care practitioners about how to generate questions from clinical encounters, with realistic expectations over the length of time required to adequately provide information.
Whilst the Australian primary care health service reform agenda has included important developments such as the establishment of divisions (and their recent move to outcomes based funding) and the General Practice Evaluation Programme, there has been little guidance for these activities from a coherent primary care policy framework.
Given these issues caution should be exercised in the reform of federal-state relations in health. Radical change, that is, the states relinquishing their control over health, would see the loss of the considerable advantages of federalism. There may be a loss of policy diversity and ability to experiment, fewer checks on central government with regard to medical ethics and a possible decrease in responsiveness to needs of voters. Radical change may also be so unpalatable to the states that they refuse any type of reform at all.
The Council, consisting of health experts (academics and clinicians) with federal and state health bureaucrats in an advisory role would be able to set national practice standards and ensure compliance with national guidelines by making funding contingent upon their achievement. Improved reporting and accountability to the Council would accompany the flow of funds from Commonwealth to states. (Epping-Jordan; Pruitt; Bengoa; Wagner, 2004 p. 299305)
The total amount of funding for hospitals would be determined using the same model across all states (there has been more than ample time since the introduction of casemix funding in the early 1990s to develop a uniform structure between states). (Hollander, 2006 p. 33-47) The states have failed to deliver in policy areas where they are supposed to hold the advantage, most notably in rural and regional health care, and are going to have to accept an increased degree of Commonwealth intervention over the coming years to resolve the problems of increased public hospital expenditure and poor distribution of resources. (Bodenheimer, 2002 p. 1775-1779) However our federal system still has much to offer health and history has shown that cooperative federalism can assist rather than detract from reform of a sector.
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