Grattan Institute findings also reflect the focus on VPE being mulled by the Medicare taskforce.
The Grattan Institute has called for the introduction of a blended funding model that would allow GP practices access both to MBS benefits and funding to support a GP-led multidisciplinary team.
- General practice becoming a “team sport”, with multiple clinicians working under the leadership of a GP to provide more and better care; dismantling the regulatory and funding barriers that force GPs “to go it alone”
- A new funding model that enables GPs to spend more time on complex cases, by combining appointment fees with a flexible budget for each patient, based on their level of need
- Greater clarity and support from government about where general practice is heading, with support and accountability for getting there; PHNs implementing key measures within the report to show if the system is working
“A system designed for an earlier era hasn’t been updated to respond to the rise of chronic disease, or to tackle gaping disparities in access to care, rates of disease and life expectancy,” the report said. “The complexity of GP work has grown immensely, as the population has grown older, and rates of mental ill-health and complex chronic disease have climbed. But the model for general practice has changed little.”
The paper claims the $250 million per year allocated by the government to improve Medicare over four years can fund its recommendations. Meanwhile, the Strengthening Medicare Taskforce, which reports back to government at the end of the year, is deciding how those funds should be spent.
The report writers are calling for the government to fund 1000 new nurses, physiotherapists, mental health clinicians, pharmacists, and other allied health workers in communities with the greatest need to work alongside GPs within general practices to provide fee-free care.
It compares general practice in Australia to those in other countries where instead of providing the bulk of every patient’s care personally, “GPs’ clinical time is prioritised: GPs make the most complex diagnoses, they treat patients with acute (severe and sudden) problems and intervene in stubbornly difficult chronic cases, and they train team members. Other team members support patient self-management, arrange for routine periodic tasks (for example, the regular blood, eye, and foot checks people with diabetes need), and ensure appropriate follow up.” It cites the use of physician assistants, whose tasks include “taking patient histories, examining patients, making specialist referrals, diagnosing conditions, or prescribing drugs”, as prevalent in the US but almost non-existent in Australia.
To reduce the waiting time to see a specialist, the report recommends “contracting specialist advice” for GPs without their having to refer complex care patients to private specialists or hospital waiting lists.
An independent commission should be engaged to remove the regulatory barriers that prevent primary care workers from safely using all of their skills, and to explain the new rules clearly.
RACGP president Dr Nicole Higgins said the proposed form of multidisciplinary team would need to be led by a GP.
“It has to be GP leadership of multidisciplinary care within general practice,” Dr Higgins said. “Fragmentation and siloing off, as has happened with pharmacy, and breaking down that relationship and continuity of care with a GP increases costs and actually reduces the quality of care.”
The funding of new clinicians would be crucial, she added.
“GPs work really well with our fellow health professionals, our nurses, pharmacists and paramedics,” Dr Higgins said, “but it’s the whole primary healthcare workforce that’s in difficulty, not just general practice. Borrowing from one profession to fill a hole in another is not going to work, so the government has to increase primary healthcare funding and GPs are at the centre of that primary care team.”
According to the report, a new funding model could support team-based chronic disease care, match funding with need, and improve access to primary care. In practices that opt in to the new model, access to MBS items for nurse practitioners and physician assistants could be expanded.
In rural areas, where access to care is low or at risk, the government should fund PHNs to support at-risk practices or set up new services in partnership with states and local hospitals. According to the report, PHNs should be given “real powers to shape markets by rolling out the new funding model, the new workforce roles, and specialist support”.
However, Dr Higgins said she was concerned about the role the PHNs might play.
“My concern is about some of the funding that’s been earmarked [for practices] going through PHNs,” she said. “It must go directly to GP practices and their patients and they shouldn’t have to go through another layer of red tape. That would make it more complex when what we’re calling for is a simplified model.”
AMA vice-president Dr Danielle McMullen said one strength of the Grattan report was that it “had pretty broad agreement” with the primary care 10-year plan.
“It has some of the same basis around needing to strengthen general practice and some reform of funding, particularly around flexible funding models in the chronic and complex disease space,” she said.
“One point of difference [between the AMA and the report writers] is that they say the Medicare model is ‘broken’. We say that overall, Medicare funding is not currently fit for purpose but that doesn’t mean fee for service is completely broken and we think it should still remain the bedrock of funding.
“But on top of that, in addition to fee for service, we also need that flexible funding for better, holistic patient care in those patient-centred, GP-led multidisciplinary teams.”
One aspect of the report that is attracting criticism is the authors’ rejection of the widely cited impending GP shortage. Report authors Peter Breadon and Danielle Romanes said in an opinion piece in today’s Nine newspapers that the facts did not bear out that lower Medicare rebates and a GP shortage (except in rural areas) were behind the primary care crisis.
Dr McMullen said the AMA strongly rejected this.
“We did a research report, released in the past few weeks, that shows we will be 10,600 GPs short by 2031,” she said. “That’s fairly consistent with a similar workforce research report commissioned from Deloitte, and their figure was around 11,000. So we have two independent workforce research papers showing a shortage coming up.”
Leanne Boase, president of the Australian College of Nurse Practitioners, said while there was some value in the report, it was important to remember who needed to benefit from improvements to primary care.
“We have forgotten that healthcare actually doesn’t belong to health professionals at all, it belongs to consumers or patients and we need to be reminded of that,” she said. “In everything I’ve read – in every report that comes out – I’m seeing it.
“If we’re improving it for health professionals, that doesn’t necessarily guarantee that service [for patients]. We should be improving it for the patient primarily, and then looking at how health professionals can work within that system.”
