australia’s primary health care 10 year plan 2022-2023

Responses to consultation questions on the Australian Primary Health Care 10 Year Plan 2022-2032.

8. reform stream 1: Future-focused health care – Action area A: Support safe, quality telehealth and virtual health care (300 word limit)

cohealth supports introducing universal voluntary patient registration to enhance continuity of care. It is imperative that the reference to ‘people registering with their accredited general practice or ACCHS’ be extended to include community health services.

The model of community health services in Victoria provides integrated primary health care (including general practice, nursing and allied health), mental health and diverse social support services. Community health services engage with community members in planning their health and social services, are accessible to all, especially the most vulnerable and marginalised people, and play a critical role in filling gaps left by other parts of the health system.

As such, voluntary patient registration is well suited to community health and we encourage its adoption within the sector as a platform for funding reform.

Continuing MBS telehealth is supported, and community health services should be added to the list of eligible providers.

At the same time, it is important to recognise that while digital health improves access to health care for some groups, and has been vital to continuing health care during the pandemic, in our experience it does not suit everyone. Consumer choice must be central to the mode of service delivery.

In addition to preference, many people face barriers to using digital health methods due to the cost of devices and data, poor or no reception and the need for assistance to build capacity to utilise technology. The Plan would be strengthened by including provision to support people who face barriers to accessing the technology required to take advantage of telehealth and virtual healthcare. This may be what the Plan refers to as ‘patient-end supports for telehealth’. If so, cohealth recommends that the Plan more clearly explain this term, and that the provision be extended to all people experiencing barriers to using digital healthcare.

9. reform stream 1: Future-focused health care – Action area B: Improve quality and value through data-driven insights and digital integration (300 word limit)

Improving data collection and digital integration is vital to integrated care and improving health care outcomes. cohealth’s experience of operating numerous client data platforms (for general practice, allied health, oral health, mental health etc) is that all have different requirements and do not easily work well together. Nor do they integrate with other health data systems, such as those operating in hospitals. This increases the time practitioners spend recording patient information and checking records and can hamper the provision of holistic health care. Working towards system interoperability, and adequately resourcing this work, is essential to realise the Plan’s goals of integrated, multidisciplinary care.

All sectors of the primary health care system must be included in data development and linkage projects supporting integrated and person-centred care. Community health services have extensive experience managing and attempting to integrate multiple patient record systems that would provide valuable input for this work.

We encourage the involvement of community health in trials that aim to strengthen primary health care data sharing arrangements for non-commercial purposes.

10. reform stream 1: Future-focused health care – Action area C: Harness advances in health care technologies and precision medicine (300 word limit)

The community health sector provides care for some of the most vulnerable and marginalised people in our community. Our clients have unequal access to digital technologies due to the cost of devices and data and differences in capacity such that reforms in this area have the potential to exacerbate health inequalities. Any investment in digital technology and online platforms needs to be coupled with an investment in improving access and utilisation of digital technologies more generally.

The ‘future focus’ of the Plan would be strengthened by broadening the emphasis of this Stream to shift the health system away from treatment and towards wellness, a goal of the Plan. The current focus on harnessing technological changes needs to clearly articulate a greater role for prevention, health promotion and health literacy.

11. reform stream 2: Person-centred primary health care, supported by funding reform – Action area A: Incentivise person-centred care through funding reform, using VPR as a platform (300 word limit)

Stream 2 acknowledges that ‘the starting point for this stream of actions is equity: no individual or population group should be disadvantaged when accessing health care services’. cohealth strongly supports equity as a key principle of the Plan and recommends that equity be an underlying principle of the entire Plan.

cohealth recognises the benefits of Voluntary Patient Registration (VPR) and urges that any system of VPR include community health services, in addition to general practices and ACCHS.

Funding reform to ‘support quality bundles of care and improved outcomes for additional registered populations’ is welcome, particularly supplementing the fee for service approach with blended models that incorporate block funding for some groups.

Community health services provide high quality integrated care for people with complex needs that is not recognised by the fee for service general practice funding model, which currently incentivises volume over quality.

It is important that incentives are structured in such a way that delivers timely and appropriate care to those who have the greatest need, and that practices are not able to ‘cherry pick’ more straightforward patients and avoid registering patients with high needs.

We encourage a change to the funding model that recognises the complex care required for a high need patient cohort and rewards high quality, integrated primary health care rather than throughput.

Rewarding quality bundles of care through new Service Improvement Payments will improve health outcomes for the identified groups. cohealth supports the priority placed on older Australians and people experiencing mental illness. We suggest prioritising incentives for parents and children in the first 2,000 days to the short term (1-3 years), rather than the medium term in the Plan, recognising the importance of these formative years to long term health.

We would welcome the opportunity to trial new funding models within our large, integrated community health service.

12. reform stream 2: Person-centred primary health care, supported by funding reform – Action area B: Boost multidisciplinary team-based care (300 word limit)

Integrating multidisciplinary physical health, mental health and social support services is central to the work of community health services. As such, community health has extensive experience operating with a multi-disciplinary workforce and supports the goal of boosting the workforce.

The scope of the multidisciplinary workforce should be broadly defined to include all those who contribute to improved health outcomes. In addition to general practitioners, nurses and midwives and allied health professionals the workforce included in the Plan should encompass peer and lived experience workers, bi-cultural workers and social prescribing link workers.

13. reform stream 2: Person-centred primary health care, supported by funding reform – Action area C: Close the Gap through a stronger community controlled sector (300 word limit)

cohealth supports the direction of these actions particularly the focus on self-determination and culturally safe trauma-informed care. Adequately resourcing ACCHS to ensure they can respond to the holistic needs of their communities is vital. We welcome the steps to improve cultural safety across all primary health care services to ensure that Aboriginal and Torres Strait Islander people receive culturally safe trauma-informed comprehensive primary care whether they attend ACCHS, community health or general practice services.

14. reform stream 2: Person-centred primary health care, supported by funding reform – Action area D: Improve access to primary health care in rural areas (300 word limit)

cohealth supports the actions to improve access to primary health care in rural areas. Community health services operate in many regions of Victoria and can provide advice about how to successfully deliver of integrated multi-disciplinary primary care in rural and regional areas.

We understand the need to increase the Rural Bulk Billing Incentive for rural and remote medical practice however this seems to be inconsistent with the earlier goal of moving away from purely fee for service funding models. Given this change acknowledges the increased costs of providing care in rural and remote settings, it should also be available to community health services in recognition of the increased cost of delivering healthcare to a population cohort with complex needs.

15. reform stream 2: Person-centred primary health care, supported by funding reform – Action area E: Improve access to appropriate care for people at risk of poorer outcomes (300 word limit)

cohealth supports the goal of improving access to appropriate care for people at risk of poorer health outcomes. Despite Australia’s excellent health care and high international health rating, we do not achieve as well on health equity. Many people, particularly those experiencing disadvantage, are at risk of poorer health outcomes. cohealth recommends that improving access to care for people at risk of poorer health outcomes be elevated to a Plan objective, in addition to this action area.

This action area can be strengthened by including provisions addressing the barriers to accessing care, such as:

• High out-of-pocket expenses. The cost of GP appointments, medication and allied health care prevent or delay people from seeking the care they need, leading to poorer health outcomes and creating future costs[1]
• Feeling unwelcome in services
• Lack of culturally safe services and resources in appropriate languages
• Lack of services in the local area
• Opening hours that do not fit with work and other commitments
• Lack of childcare
• Short appointment times
• The digital divide, where lack of coverage, cost of devices and data or preference for in-person contact mean the benefits of digital health care are not available to all
• Need for outreach services
• Inadequate provider knowledge of the impact of personal circumstances on health

Community health services employ innovative approaches to address these barriers, including outreach, community engagement, employing bi-cultural workers and lived experience workers, longer appointment times and providing services at low or no cost.

Delivering general practice services through this model is expensive and is not rewarded by a fee for service model. In the short term we recommend an additional patient loading given the complexity of our patient cohort with a longer term move towards a blended funding model that incentivises the delivery of high quality, integrated care over throughput.

16. reform stream 2: Person-centred primary health care, supported by funding reform – Action area F: Empower people to stay healthy and manage their own health care (300 word limit)

Ensuring that people have the information they need, and it is available in accessible formats, is critical to enabling them to remain healthy and manage their own health care. The Plan identifies that ‘information is routinely available in accessible formats including plain English, Easy Read, Auslan and community languages’ as a future state (7-10 years) action. This should be given a much higher priority, ideally with work in this area being undertaken in the short term (1 – 3 years) and continually reviewed and revised.

Consumer engagement must be central to all work in this action area to ensure that resources and approaches best meet community needs.

The social determinants of health – the environments in which people grow, live, work and age – are a major contributor to health inequalities. People who have very low incomes, insecure work, inadequate housing or subject to racism and discrimination can face significant barriers to obtaining the basics of healthy living and accessing health care. To empower people to stay healthy the Plan needs to articulate goals that provide the foundation for addressing these – ensuring all Australians have an adequate income, secure and stable housing, can live free from discrimination and abuse and reducing the risks from climate change – and actions for achieving them.

17. reform stream 3: Integrated care, locally delivered – Action area A: Joint planning and collaborative commissioning (300 word limit)

Community health services have lengthy experience working closely with Federal, state and local governments – including PHNs and hospital networks – and a wide range of community stakeholders to improve the health outcomes of the communities they work with, and we recommend that this is referenced in the Plan.

Systematic, joint jurisdiction planning of primary health care services is welcome, as are regional plans and collaborative commissioning approaches for groups at risk of poorer healthy outcomes. cohealth urges that the priority level be raised for groups identified for action in the medium term – care in the first 2,000 days and the health of people with disability, CALD communities, LGBTIQA+ communities and those experiencing socio-economic disadvantage – due to the poorer health outcomes, and in the case of first 2,000 days, the critical importance of this period to long term health and wellbeing.

Caution needs to be exercised in using collaborative commissioning approaches to ensure that the lessons from past processes are heeded. Commissioning has at times increased competition, undermined cooperative service approaches and disrupted the very service systems it was meant to be improving.

18. reform stream 3: Integrated care, locally delivered – Action area B: Research and evaluation to scale up what works (300 word limit)

cohealth supports the intention of this action area, to evaluate and scale up primary care models that work and to conduct regular monitoring and evaluations on this Plan.

Community health services are already providing integrated, multi-disciplinary primary health care, and provide an established model for research and evaluation and the benefits of investing in comprehensive health care to deliver health outcomes and prevent avoidable hospital admissions.

19. reform stream 3: Integrated care, locally delivered – Action area C: Cross-sectoral leadership (300 word limit)

Cross sectoral leadership of primary health reform and collaboration must include all relevant stakeholders, including consumers and community health organisations such as cohealth.

20. Please provide any additional comments you have on the draft plan (1000 word limit)

cohealth supports the direction of reforms articulated in the Plan. Australia’s primary health care system has many strengths, providing high quality health care for many Australians. However, there are also significant weaknesses in its structure and funding. These hamper effective integration and provision of comprehensive care across the primary health care sector, with the acute health sector and non-health services that are vital to health and wellbeing. These barriers have the biggest impact on those who have the greatest health needs.

The Victorian community health model, similar to the ACCHO model, already addresses many of these challenges. Community health centres are team based, multidisciplinary settings that integrate primary care with other health and social services. The model is based on the social determinants of health, and services are place-based with each centre having responsibility for defined population groups. Community health services engage community members in planning their health and social services, they are accessible to all, including the most vulnerable and marginalised people, and they play a critical role in filling gaps left by other parts of the health system.

Community health delivers high quality primary care to people with complex needs but this is not reflected by the current fee for service funding model, which rewards volume over quality. We support funding reform that enables community health to continue delivering high quality primary health care to people who face barriers to accessing services.

The sector has significant experience that will be invaluable to primary health care reform, and cohealth urges that the knowledge and contribution of the sector be included in Australia’s Primary Health Care 10 Year Plan 2022 – 2032. Community health providers must be included in the Implementation Oversight Group to be established in the first year of the plan (pages 3 and 40).

It is cohealth’s view that the community health model provides a clear foundation for primary health care reform.

cohealth supports the shifts in primary health care illustrated on page 9 of the draft Plan, particularly the move from an illness system to a wellbeing system. From our experience delivering integrated, multi-disciplinary care to people experiencing disadvantage we offer the following recommendations to strengthen the draft Plan:

1. The consumer must be central to the Plan and in all aspects of primary health care provision, including in its objectives and planning, implementation and evaluation through processes such as co-design to ensure a safe environment. To reflect this emphasis Stream 2: Person-centred primary health care, supported by funding reform should be the first of the Plan’s streams.
2. The Access objective of the Plan (page 1) would be strengthened by clearly articulating that measures must be implemented to address the barriers to health care faced by people experiencing disadvantage, as they are at most risk of poorer health outcomes. Action to support health outcomes should be a priority across all aspects of the Plan.
3. Social determinants of health – while the draft Plan acknowledges the ‘need to consider the social determinants of health’ (page 4) no system responses to them articulated in it. The circumstances in which people grow, live, work and age and the structural conditions in society which lead to unequal living conditions and affect the chances of a healthy life – the social determinants of health – are a major contributor to health inequities.Given the significant contribution the social determinants of health have on health outcomes, and that primary health care can only be most effectively provided if they are addressed, cohealth recommends the Plan include actions to address the social determinants of health, particularly:
   • Racism and discrimination – operating at individual and systemic levels this has many harmful physical and mental health impacts.
   • Climate change – the greatest health emergency facing our planet. The direct and indirect impacts of climate change will impact disproportionately on marginalised and vulnerable communities. Urgent and substantial action is required to reduce the threats posed by climate change and to adapt to these threats.
   • Poverty and inequality – low socio-economic status is a key underlying factor common to almost all people experiencing health disadvantage and lies at the heart of health inequality. The impacts of low income are exacerbated by expensive, insecure and poor-quality housing, insecure employment, unemployment and underemployment; and location that is removed from services, jobs and health care. Poverty can be both a determinant and a consequence of poor physical and mental health. With more than one in eight Australian adults and more than one in six children living in poverty it is essential to address this underlying driver of poor health if we are to improve the nation’s health.
4. Oral health care. Traditionally missing from any conversation about primary care, and similarly from this draft Plan, is the place of oral health care, despite the draft Plan acknowledging that dental services are part of the primary care sector (page 4). While the links between oral health and general health are clear the two systems often work in isolation and have separate training, funding, regulatory and administrative systems. This adds to system complexity and can be detrimental to people’s health.
   cohealth operates three public dental clinics as a key part of our service offering. The advantages are clear – oral health practitioners regularly refer patients to cohealth primary care providers such as GPs, mental health services and allied health practitioners (and vice versa), and collaborate about their care, ensuring even more comprehensive health care than is envisaged in the Plan. cohealth recommends the Plan include actions to overcoming the divide between primary health care and oral health care and better integrate the two sectors to improve the health of individuals and communities.

Finally, the draft Plan notes the importance of providing health information in accessible formats including plain language (Stream 2, Action area F: empower people to stay healthy and manage their own health care). Consistent with this approach, the final version of the Plan will be strengthened, and be a more accessible resource, by being written using health literacy principles

[1] https://grattan.edu.au/wp-content/uploads/2019/04/916-Commonwealth-Orange-Book-2019.pdf