PHNs should have matured: RACGP

Eight years on from their naissance PHNs remain poorly managed and primary care is arguably increasingly disjointed, says an expert.

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The RACGP has recommended a suite of measures to better monitor PHN performance, amid criticism of shabby oversight, poor governance systems, badly managed conflicts of interest and the potential of wasted taxpayer money.

This week, the college released its 12-page submission to the Australian National Audit Office (ANAO) detailing its critical commentary on the “insufficient” oversight of the Department of Health and Aged Care’s 31 Primary Health Networks (PHNs) across the country.

Among its denunciatory observations: a hyper fixation on service provision rather than ensuring outcomes are reflective of the needs of stakeholders and insufficient performance management, potentially squandering taxpayer money.

“Such inefficiency is unacceptable when general practice is experiencing some of the most significant challenges in its history and struggling to remain financially sustainable,” the submission read.

“Patients deserve services that are not just accessible but also deliver substantial improvements to their health.”

The college also suggested DoHAC had poorly managed conflicts of interest and that its insufficient oversight and prioritising profits over best practice principles had resulted in inconsistent governance structures.

RACGP expert committee on funding and health system reform vice chair Dr Emil Djakic told The Medical Republic that the submission reflected feelings of disconnect between the PHNs and their expected role, namely acting as the interface between different parts of the health system, felt by members of the college from across the country.

“Any bureaucracy is going to be a target for criticism about activity being KPIs rather than productivity measures,” said Dr Djakic.

“Our submission clearly highlights concern that there doesn’t appear to be any measures to show evidence of outcomes… that are of benefit to patients.”

According to Dr Djakic, in his experience from his “own local patch” working as a regional doctor in Tasmania, the direct relationship between general practice and local hospitals has worsened since he started his practice in 1992.

“[Primary care] is probably more disjointed now, for a GP, than I’ve ever seen,” said Dr Djakic.

“As GP member organisation, [the RACGP] are rightly arguing that we feel like those areas of connectivity with general practice weaker than they should be at the moment,” he said.

“I don’t believe that the PHN really is the strongest advocate for us in that space.”

However, added Dr Djakic, echoing the colleges submission, not all PHNs can be painted with the same brush.

“There’s diversity in performance … we can’t be wholly critical of all of them.”

The disconnect cannot be blamed solely on PHNs, added Dr Djakic, it is a wider structural problem.

The fiscal stress of general practice as a business, workforce stresses and compliance obligations, among others, have led to a “loss of appetite” for general practice, said Dr Djakic.

“The college’s submission is clearly recognising that there is a role for an organisational structure to help try and glue together a whole range of businesses in primary health and general practice particularly,” he said.

“But without some value for money and value for outcome propositions, it’s very hard to ensure that we’re all working in the same direction.”

Unsurprisingly, number one on the list of 14 RACGP recommendations was a movement towards “delivery of outcomes rather than the provision of services”.

“The community and primary care stakeholders of PHNs need to be involved in determining these indicators to ensure outcomes are meaningful,” said the college.

The RACGP recognised that PHNs may struggle where state governments and stakeholders were hesitant to engage.

But given the eight years that have passed since PHNs were first introduced in 2015, they should “have moved beyond the stage where initiating and implementing programs is challenging”, the college added.

“While PHNs remain young institutions, the indicators they are currently required to meet set the bar too low and do not sufficiently drive or measure outcomes,” it said.

“PHNs should now be sufficiently mature that they can be expected to initiate and implement complex programs without being driven by performance management.”

The recommendations also highlighted the need for PHNs to show that how they support local general practices is in line with local needs.

The college suggested regular audits and mandatory governance processes and structures, to improve consistency of outcomes.

Scrutinising the “insufficient” level of consultation and collaboration between PHNs and Aboriginal Community Controlled Health Organisations (ACCHOs), the college suggested the government move away from “optional guidelines” towards mandatory standards for Aboriginal and Torres Strait Islander consultation.

It also recommended new indicators to measure hospital discharges, with summaries provided to GPs within 48 hours, and to measure attempts by PHNs to improve the primary and secondary care interface to reduce “potentially preventable hospitalisations and improving the flow of data and communications”.

Submissions to the ANAO will be accepted until 6 December, with the report due to be tabled in March next year.