Post on 07-Nov-2014
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Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Strengthening Primary Care in Australia: Challenges and Opportunities for System Reform
Suzanne Robinson Associate Professor and Director of Health Policy and Management at Curtin University
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Associate Professor Suzanne Robinson
Director of the Health Policy and Management and Health Information Management at the School of Public Health, Curtin University
WA Health Systems policy and Research Network
Research interests include health policy and systems research, economic evaluation
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Outline of presentation
Australia health system performance – national and international
Health system reform – The role of Primary care
The MCL vision
The MCL reality
The MCL possibility
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The Facts: Australia at a glance
23 April 2013: 23
million people
WA 2.45 million 2012
annual increase of 3.4 per cent
Average life expectancy male 79 yrs female 84 yrs
Average LE Indigenous pop male 59.4, female 64.8
64% of people live in capital cities15% of indigenous live in remote areas and 49% in very remote areas.
Unemployment Rate in Australia increased to 5.60% 2013
Australia was around 12t- 14h wealthiest among OECD countries
Australia top 20 most expensive citesSydney 7th
Melbourne 8th
Perth 13th
In 30 yrs the proportion of the population over 65 yr will almost double to around 25 per cent.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
A Typical Day in Australia
Source: BEACH (Bettering the Evaluation and Care of Health) Survey
Patient Complexities
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Australia health system performance
Expenditure on health in Australia was estimated to be $130.3 billion in 2010-11, up from $77.5 billion in 2000-01
The two largest components of the increase in health expenditure were public hospital services, which grew by $2.2 billion in real terms, followed by medications ($2.1 billion).
In 2009–10, the estimated national average level of expenditure on health was $5,251 per person.
Western Australia ($5,128 per person) was 2.3% below the national average,
Northern Territory’s ($6,549 per person) was 24.7% higher than the national average. T
The average annual real growth per person was highest in South Australia and the Northern Territory (4.3%) compared with the national average of 3.9.
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Disease statistics
Cancer is Australia’s leading broad cause of disease burden (19% of the total), followed by cardiovascular disease (16%) and mental disorders (13%).
Around 1 in 5 Australians aged 16–85 years has a mental disorder at some time in a 12-month period, including 1 in 4 of those aged 16–24 years.
The burden of Type 2 diabetes is increasing and it is expected to become the leading cause of disease burden by 2023.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Disease statistics
Tobacco smoking is the single most preventable cause of ill health and death in Australia.
Rates of sexually transmissible infections continue to increase, particularly among
The perinatal death rate of babies born to Indigenous mothers in 2007 was twice that of other babies.
It is estimated the number of people living with dementia is projected to triple to around 900,000 by 2050. Dementia is one of the major reasons why older people enter residential aged care or seek assistance from community care programs.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Performance: How are we doing internationally? Australia’s health system is
amongst the best in the world
However, there is still room for improvement
Australia’s economy remains strong in comparison to others – especially Europe and USA
WA does well economically
Evidence suggests that it is often difficult to make changes during
times of plenty!
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Achieving reductions in spending Ireland, achieved through cuts in wages or the fees paid to
professionals and pharmaceutical companies, and through actual reductions in the number of health workers.
Estonia cut administrative costs in the ministry of health and also reduced the prices of publicly reimbursed health services.
Investment plans have also been put on hold in a number of countries, including Estonia, Ireland, Iceland and Czech Republic
Efficiency gains pursued through mergers of hospitals or ministries, or accelerating the move from in-patient hospitalisation towards out-patient care and day surgery. The use of generic drugs has also been expanded in a number of countries.
Increase in out of pocket payments. For example, Ireland increased the share of direct payments by households for prescribed medicines and appliances, while the Czech Republic increased users’ charges for hospital stays.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Australian Health Outcomes: OCED data suggests: In-hospital case fatality rates within 30 days of admission
for acute myocardial infarction (heart disease) are significantly lower than the OCED average (3.2% vs 5.4% in 2009).
Australia had a higher rate of death in hospital following ischaemic stroke (5.6% vs OECD average of 5.2%)
Avoidable hospital admissions for (Chronic obstructive pulmonary disease) COPD and asthma complications are higher in Australia than the OECD average. For COPD Australia rate was 312 per 100,000 adults (OECD average 198) and asthma admissions, Australia was 67 (OECD average of 53).
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Rising obesity pushing up healthcare spending % of obese among adults
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Comparison of seven nations
Davis, K. Schoen, C. and Stremikis, K. (2010) Mirror, Mirror on the wall, how the performance of the U.S. health care system compares internationally 2010 update, The Commonwealth Fund
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Why the growth in demand for primary care?
Increasing availability of medical cures and technology (surgical techniques, anti-depressants, etc)
Rising need for community-based care to support people with long-term health problems (chronic disease management)
Desire to contain costs and avoid hospitalisation Changes in hospital care leading to shorter stays and
associated need for more community support
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Why strengthen primary care PC orientation is proportional to health outcomes
The more PC orientated, the higher the health indicators rankings
Countries that are more PC orientated have lower overall costs for their health services
Their efficiency is higher
Unplanned primary care – out-of-hours care, emergencies, links with unplanned care in other sectors
The desire for better access – longer opening hours, more providers, patient choice, better pathways and diagnostics
Improving care for people with long term conditions – better pathways, managed care approaches, reducing hospital admissions
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
So what did are the overall policy and management challenges facing primary care?
Dealing with the increasing levels of chronic disease
Responding to changing societal and policy demands re access and choice
Developing more integrated forms of care that are community based and yet supported by specialist services
Addressing profound workforce pressures, especially in rural and remote areas
Assuring quality of care
Addressing issues around equity and access to services
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Health Care Reform: why?
In 2008, the Australian (Labor) Government set up the National Health and Hospital Reform Commission (NHHRC) to conduct the most comprehensive review of the health system in 20 years (MCL part of wider reform)
The current health care system was identified as being: • fragmented, contributing to cost-shifting between different
levels of government• involved too much waste • resulted in long waiting times for patients.• Services are provider rather than patient led• Inequities in health outcomes• System can’t continue with increasing pressures and
demands
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Health Care Reform: why? Unlike hospitals primary care
often lacks the investment to take a system approach.
patients often feel that their journey through a complex health system could be better coordinated and many patients, particularly those who are socially disadvantaged. - For these patents the system we have come to rely on doesn't meet their needs.
There are also gaps and inequities in access to services and variations in health outcomes between different population groups
A failure of the system to focus more seriously on disease prevention and health promotion activity.
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Health Care Reform: why?
GPs and other community providers need more support so they can have an effective, central and ongoing role in patient care.
For many GPs balancing day to day practice responsibilities and trying to reform PC and they system more widely is singularly impossible.
MCL reform allows focus on system reform.
MCL can better support GPs and their practices.
This support needs to be locally or regionally based because that's where most services are provided.
The increased demand of an ageing population is unsustainable over the longer term.
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Medicare Locals: the vision Medicare Locals (MLs) New organisations first phase 2011
61 nationally; 8 in WA
Formed as key primary health organisations as a result of COAG (Council of Australian Governments) National Health Reforms agreed to by both the Commonwealth and State Governments
MLs build on previous work of the Divisions of General Practice, (working with GPs) BUT broader than GPs
Broader primary health focus - including allied health, pharmacists, specialists, nursing, mental health, preventative health
Also better linking with the hospital and aged care sectors
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Health Care Reform Cont.
120 - Divisions of General Practice
61 – Medicare Locals
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Medicare Locals: the broader role
Can build on the work of GP divisions-
Work with Broader system -stronger engagement across the whole primary health spectrum
Linkages – acute and aged care
Extra funding – fill service gaps
Community specific needs solutions
Help support research and development in PC
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
MCL Five strategic objectives:
Improving the patient journey through developing integrated and coordinated services
Provide support to clinicians and service providers to improve patient care
Identification of the health needs of local areas and development of locally focused and responsive services
Facilitation of the implementation and successful performance of primary health care initiatives and programs
Be efficient and accountable with strong governance and effective management.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Medicare Locals: the reality Young organisations just finding
their own role and identity
Various stages development, but the momentum is significant in places
Some misconceptions about what the reform is attempting to do and poor communications on what the reform is about- by
Lack of understanding of the role of MCLs
Issues around competing interests of stakeholders
Other system incentives – e.g. funding mechanisms
It is all about relationships - Variation across MCL’s – some engaging well others less well
What’s gone before matters!
Lots of mixed feelings about MCL reform– from GPs, NGOs and other groups
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Medicare Locals: the reality
Examples of local solutions that are strengthening General Practice in some regions
Health Pathways – 10 MCLs working in this space
Diabetes planning
Work around out of hours,
Use of spatial information planning to identify gaps in services
Provision and support of important but often under-resourced or less profitable services- e.g. street Doctor
How close to medical practices is the population older than 65 that need assistance?
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Opportunities for MCLs and primary care
1.Demonstrate leadership and promote innovation in primary health care.
2.Improve the coordination and integration of primary care activities.
3.Identify needs and gaps in the local community with a focus on social inclusion.
4.Develop locally focussed and responsive services.
1.Work in partnership with key stakeholders to improve the quality of primary health care.
2.Help to drive system reform
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Delivering on the reform: what will this take? Strong and effective leadership
that can negotiate the complex and often difficult healthcare terrain
Engagement with key stakeholder groups from across the health system
Understanding of the different cultures and incentives that operate in the system
Clarity of role and communication on this
Support of the primary care sector
A passion to succeed
Commitment to improving public and patient health and a way to communicate this to the wider community
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The cost of not moving forward
At best we keep the status quo
Primary care continues to lack capacity to really influence system reform
Fragmentation and inequities grow
The evidence base around efficient and effective high quality service provision in primary care remains low
MCL experiment fails and opportunity is lost
Other?
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J