Ladders & Snakes - Consumers Health Forum of Australia
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Snakes
&Ladders
The Journey to
Primary Care
Integration
A health policy report – September 2018
Acknowledgements
We acknowledge the lands of the First Peoples upon which this report
was written and pay our respects to Elders past, present and future.
The roundtable was co-hosted by the Consumers Health Forum of Australia, The George Institute for Global Health
and the University of Queensland-MRI Centre for Health System Reform and Integration. The hosts would like to
acknowledge the generous support of Bupa Australia, the AGPAL-QIP Group of Companies, the Western Sydney
and Northern Territory PHN and COORDINARE South Eastern NSW PHN. Supporters provided unrestricted funding
to contribute to running costs of the roundtable.
The roundtable and subsequent report are independent of this funding, and co-authored by the Consumers Health
Forum of Australia, The George Institute for Global Health and the University of Queensland-MRI Centre for Health
System Reform and Integration. The views and recommendations in this report represent the outcome of the group
discussion and not any particular individual, organisation or government. (Some participants may have official
positions that differ from that presented in this report). The hosts also thank Mr David Butt from Partners2Health for
his assistance facilitating the roundtable and compiling the report. The hosts would also like to thank our consumer
and clinical co-leads who facilitated group discussions.
Proudly supported by
Gold supporters:
Silver supporters:
Project team
The roundtable and independent report was a joint production of The George Institute for Global Health, the Consumers
Health Forum of Australia and The University of Queensland MRI Centre for Health System Reform and Integration.
Maya Kay Carolyn Thompson Consumer leads
Head of Stakeholder Engagement and Policy Officer
Communications, The George Institute, Australia Consumers Health Forum of Australia Linda Beaver, Jan Donovan, Belinda
MacLeod-Smith, Patrick Frances, and
Chelsea Hunnisett Alexander Baldock
Communications & Stakeholder Engagement Design Manager Diane Walsh
Coordinator, Communications, The George The George Institute for Global Health
Institute, Australia
Provider/clinical leads
E. Richard Mills Mark Diamond, Dr Keng Sean Lim,
Director, Global Communications and Advocacy Dr Tim Usherwood, and Katharine Silk
The George Institute for Global Health
2 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018
Snakes & Ladders
The Journey to Primary Care Integration
This report presents the arguments as to why all political of Health Care Homes (HCHs), along with associated
and other leaders must act now to transform Australia’s bilateral agreements between the Commonwealth and
health system to ensure it is sustainable, effective, the states and territories on coordinated care reforms
efficient, and leads to greater satisfaction for both to improve patient health outcomes and reduce
consumers and service providers. avoidable demand for health services. However, the
The report provides priorities for those leaders to system and funding remain heavily tipped towards
maximise opportunities to achieve better health and hospital and other institutional care as the hub of most
wellbeing outcomes for individuals, their families and importance. Equally it is hospital and institutional care
communities, and thereby unlock both social, capital and that attracts most of the public and media scrutiny and
economic benefits for Australia. often is a political focus.
The recommendations have been synthesised and Re-orientation towards strong, integrated primary
derived from expert discussions and reflect established health care as the driver of better health and wellbeing
evidence that health systems with strong primary outcomes, needs solutions that help to overcome some
health care are more efficient, have lower rates of of the inherent challenges in Australia, with the aim of
hospitalisation, fewer health inequalities and better health ensuring:
outcomes including reductions in rates of people dying. • A consumer centred approach
While Australians generally enjoy some of the best • Continuity of care and integration of services around
health outcomes in the world, it is widely recognised the the needs of individuals, families and communities
current health system is under increasing strain. Factors through clear care pathways
leading to this strain include the growing burden of • Equitable access to safe and high-quality care
chronic disease, an ageing population, an unsustainable
• A seamless passage through the system regardless of
funding system which includes adverse incentives to
who funds, governs or provides services
achieve volumes of services rather than better outcomes,
workforce challenges, and digital innovation which is • Coordination of service planning and delivery
driving solutions but also comes at a cost. within the sector and with other health, social, and
economic sectors which impact on the health and
Many OECD countries have recognised the
wellbeing of individuals and communities
importance of sustainable and effective integrated and
comprehensive primary health care which is consumer • Enhanced sustainability of a system which is under
(patient) centred and takes a whole-of-person approach ongoing pressure to meet the population’s needs
to better meet the needs of individuals, families and at the same time as containing costs and delivering
communities. high-value care.
Australia has made some significant moves to strengthen
its primary health care system. Examples include the
formation of Primary Health Networks (PHNs) and trials
We hope you enjoy this report
Professor David Peiris Leanne Wells Professor Claire
Director Cheif Executive Officer Jackson
Health Systems Science Consumers Health Forum Director
The George Institute of Australia University of Queensland-
for Global Health MRI Centre for Health System
Reform and Integration
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 3
Snakes
About & Ladders
this report
On 1 August 2018, the Consumers Health Forum of In using the term ‘consumer’, we mean people who use
Australia (CHF), The George Institute for Global Health health services, as well as their family and carers. This
and the University of Queensland MRI Centre for Health includes people who have used a health service
System Reform and Integration convened a special in the past or who could potentially use a service in
policy roundtable with key stakeholders across the the future.
health sector. The roundtable – Snakes and Ladders: By primary care, we mean those services which usually
The Journey to Primary Care Integration – is part of a are the first point of contact in the health system, such
series of roundtables, co-hosted by The George Institute as general practice, pharmacy, allied health, nursing,
for Global Health and the Consumers Health Forum of dentistry, Aboriginal and Torres Strait Islander health
Australia. services (including Aboriginal Community Controlled
Participants were people who have been engaged in Health Organisations), health promotion and a broad
the conversation on primary health care reform so far range of community health services.
and those who have a track record in implementing Primary care is a component of primary health care,
innovative reforms in integrated primary health care. It which includes a broader range of those social,
included consumer advocates, health care providers, economic and environmental factors which influence
clinicians, academics, industry, government and policy health, social and emotional wellbeing, including social
experts from across Australia. connectedness, childhood development, housing,
The purpose of the roundtable was to formulate education, employment, engagement with the justice
independent recommendations on pressing changes system and the physical environment.
needed to transform the health system and ensure it Integrated care was described at the workshop as
is more responsive to consumer needs. This objective “joined-up care for everyone when they need it and
demands an increased emphasis on integrated primary where they need it”. The principles adopted by CHF
health care and ensuring it has a stronger place in the to describe patient-centred care were also used to
health system. describe “integration”:
The aim of the roundtable was not to debate whether • Appropriate care
primary health and integrated care reform is needed,
• Accessible and affordable care
but to focus on transformation and implementation.
The objective was to shape near, medium and longer- • Consumer involvement in planning and governance
term recommendations about how Australia can move at all levels
towards a strengthened primary health care system at • Trust and respect
all levels. • Coordinated and comprehensive care
Participants considered: what specific recommendations • Whole-of-person care
can be made to effect change? They thought about the • Informed decision making.
system levers which need to move first in year one, year
three and year five and came up with concrete, on-the-
ground actions which form a logical pathway to advance
change over time. This would progressively build a
platform from which achievement of short and medium-
term goals will lead to the achievement of longer term
goals.
Integrated care happens when organisations work
together to meet the needs of local populations. Some
forms of integrated care involve local authorities to
help achieve objectives, and the most ambitious forms
of integrated care aim to improve population health
by addressing the causes of illness and the social
determinants of health.
4 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018
Our approach
There have been many reports, strategies, policies and changes to build that system and reap the benefits for
frameworks over time which have provided the evidence consumers, providers, taxpayers and society.
and established the case for primary health care As a basis for framing this report, the ‘4S’ framework –
renovation and transformation. They include: self, service, setting and system – was used to analyse
• The Productivity Commission report, Shifting where Australia is currently positioned on integrated
the Dial: 5-year productivity review (2017), which primary health care and to identify areas for action. This
recommended the creation of a Prevention and framework is broadly based on work undertaken to
Chronic Condition Management Fund for PHNs and analyse joint working across health and social care in the
LHNs, as well as reconfiguring the health care system United Kingdom by the UK National Audit Office. It also
around the principles of patient centred care follows the World Health Organization systems thinking
• The National Primary Health Care Strategic Framework model:
(2013), which was agreed by all Australian, state • “Self” considered key topics such as people’s
and territory governments but which has had scant experience, consumer enablement, health literacy, and
attention at an intergovernmental level ever since consumer attitudes
• The Report of the Primary Health Care Advisory • “Service” covered topics such as access, service
Group, Better Outcomes for People with Chronic delivery, workforce, new service models and new
and Complex Health Conditions (2015) which funding models
recommended consideration of bundled payment • “Settings” looked at issues including regional and
systems (a pool of funds to be used flexibly to best local settings, health and social service integration,
meet the needs of consumers, instead of the current joint planning, and consumer reported outcomes
siloed, disjointed and difficult to navigate funding measurement
system), Health Care Homes as a means of supporting
• “Systems” covered topics including governance
team-based care and improved coordination of care
models and structures, burden of disease, needs of
• The George Institute/CHF reports, Putting the diverse populations, and whole of person care and
Consumer First (2016), Patient-centred Health infrastructure essential to a high performing integrated
Care Homes in Australia – Towards Successful primary health care system.
Implementation (2016), and Going Digital to Deliver a
Healthier Australia (2018). Recognising the inevitable (and desirable) overlap within
this framework, this report utilises three domains – self,
The Council of Australian Governments (COAG) services and settings, and systems.
National Health Reform Agreement (2011) and its revised
schedules (2017) commit the Australian, state and
territory governments to cooperate and coordinate on The challenge for
primary care, with the Australian Government having governments is to meet
lead responsibility for managing primary care.
community expectations
There has been no lack of policy direction, with the
messages about what needs to change being highly across the spectrum of
consistent over a long period of time. What has been healthcare services against
missing is not the knowledge but rather coordinated
the backdrop of fiscal
commitment from all levels of Government to a clear
pathway forward and the systematic implementation constraints, escalating costs
over time of changes which can transform Australia’s and rising expectations.”
health system.
- Community Pulse 2018: the Economic
There is a need for commitment from all levels of
Disconnect. The Committee for
government to a longer-term vision of a primary health
Economic Development of Australia
care-led system which is pursued relentlessly and
consistently over time, with staged investments and
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 55 key themes and 10 priorities
for implementation and transformation
Clear the way by removing funding barriers
1. Fund equitable access to a revised model of Health
Care Homes across Australia, based on the original
Primary Health Care Advisory Group (PHCAG)
recommendations, with participation remaining
voluntary for both practices and consumers, and
including a significant shift away from largely fee for
service payment systems.
2. Strengthen Medicare through the development of
regional budgets combining Commonwealth and
State/Territory funding. These budgets would be
flexibly administered by PHNs and LHNs, prioritise
prevention and integrated primary health care and
have strong governance arrangements that mandate
consumer participation and decision-making.
Create regional solutions
3. Establish formal agreements between the
Commonwealth, the states and territories, Primary
Health Networks (PHNs) and Local Hospital Networks
(LHNs) (or their equivalent) to improve local and
regional system performance and deliver integrated,
consumer centred services.
4. Progressively empower PHNs to take greater
responsibility and accountability for creating primary
health care systems in their local areas. This includes
broadening the objectives of PHNs and devolving
additional funds from the national level to PHNs,
with greater flexibility, authority and accountability
to commission services based on population
health needs and with consumer codesign models
supported to share decision-making.
5. Require PHNs and LHNs to work together as co-
commissioners of services, to design and develop
alliance contracting arrangements with service
providers where desired outcomes are specified and
service providers are incentivised to work as partners
in achieving those outcomes.
Test and showcase innovation
6. Implement a major demonstration project to
empower consumers with complex chronic diseases
to plan and manage their health by providing
them with flexible individual funding packages –
personalised budgets – where they have choice of
services and providers (similar to the NDIS and aged
care reforms).
6 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 20187. Fund a Consumer Enablement Portal to bring consumer experience through Local Hospital
together and better promote access to a broad range Networks, Primary Health Networks and the
of high quality consumer literacy, self-management, services they fund as important measures of better
decision making tools and other information health outcomes.
resources to empower consumers to better engage • Link organisational funding, board and
and participate in decisions about themselves, their management performance contracts or
families and other support people, the services they agreements to the achievement of standards on
receive and the systems they connect with. consumer engagement and experience.
Link up the system Lead into the future
8. Recognising the importance of professional 10. Invest in the establishment of a government-led
collaboration and team-based care within care National Centre for Health Care Innovation and
settings as well as across primary, secondary and Improvement. The centre would support system
tertiary health care, introduce funding models which stewardship by testing and scaling up new models
promote joined up models of health service delivery, of care and payment systems that work for patients,
including incentives which: build capacity in the commissioning work of PHNs
• Appropriately support non-prescribing pharmacists and their co-operation with LHNs, and spearhead
in general practice national efforts to support the development of
• Establish GP Liaison Officers in all metropolitan clinical and consumer skills in leadership, change
and regional settings management and improvement science. The centre
should be a private-public partnership involving
• Promote hospital-based specialists providing
clinical, consumer, academic and industry leaders
liaison, advice, support, education or clinics within
and philanthropic funding.
general practice based on community need
• Significantly expand access to care coordinators, Further detail on these priorities is included in the next
health system and social service navigators and section on overarching priorities for action. A range
health coaches on a regional basis for those with of other priorities was identified, many of them linked
complex chronic conditions to (and in some cases enabling) these ten overarching
• Increase the numbers of Aboriginal and Torres priorities. These priorities can be found in the Appendix,
Strait Islander and Culturally and Linguistically Table 1 – A Five Year Plan on page 18. Table 1 organises
Diverse (CALD) people at all levels of the health ‘’next tier” recommendations into the steps needed
workforce over a 1-3-5 year outlook to achieve the 10 overarching
recommendations.
• Promote development, professionalisation and
employment of a peer workforce with lived
experience, with priority for mental health and
suicide prevention peer workers.
9. Recognise the important role of primary health care
information – including patient experience measures
– as fundamental to better patient management,
service development and quality improvement,
integration, and accountability. Scope and develop
a primary health care information strategy that
includes:
• A national minimum data set and performance
framework for primary health care to measure
impact and outcome of services
• Mandated measurement and reporting of
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 7The overarching priorities for action
Clear the way by removing funding barriers and for all patients connected to participating
1. Fund equitable access to a revised model of Health practices – not just those with complex chronic
Care Homes across Australia, based on the original illnesses.
Primary Health Care Advisory Group (PHCAG)
• Equitable access should be provided to HCHs across
recommendations, with participation remaining
Australia, with a general roll-out across the country.
voluntary for both practices and consumers, and
Participation in HCHs would remain voluntary for
including a significant shift away from fee for
practices and patients, however support structures
service payment systems.
should be established to assist practices that are
The Primary Health Care Advisory Group (2015) put interesting in transitioning to HCH models.
forward the Health Care Homes (HCHs) model to
This overarching priority builds on other
provide a setting where consumers with complex and
recommendations in Appendix, Table 1:
chronic conditions can receive enhanced access to
holistic coordinated care and wrap around support for • Transition from largely fee for service general practice
multiple health needs. This is currently being trialed in to a flexible funding model based on needs and
around 170 practices to date nationally. outcomes, rather than occasions of service. Over
time, consider including these funds in regional
Concerns have been raised about funding and
budgets.
implementation of the Australian model. However,
the principles which underpin the model are well 2. Strengthen Medicare through the development of
established, tested and implemented in other countries regional budgets combining Commonwealth and
such as New Zealand, the United Kingdom, and the USA. State/Territory funding. These budgets would be
HCHs provide great opportunities for transformational flexibly administered by PHNs and LHNs, prioritise
reform in the Australian health system. They aim to prevention and integrated primary health care
promote consumer-centred care and move away from and have strong governance arrangements that
a focus on activity through fee for service medicine mandate consumer participation and decision-
to a focus on outcomes. They provide additional time making.
and flexibility for general practice to take a whole-of-
Recommendations 2–4 set the platform for establishing
person approach to health and wellbeing and promote
regional budgets where funding is pooled between
interprofessional team-based approaches. They provide
the Commonwealth and states/territories to enable a
capacity for GPs and other members of the care team to
joined-up approach to commissioning services which
reach out to their patients rather than patients coming to
are consumer-centred and offer wrap around, whole of
their doors – a more connected community.
person care and access to services.
There was a strongly held view at the roundtable that: Regional budgets give the opportunity to plan, design,
• Recognising the strength of the policy settings commission and deliver services which are responsive
for HCHs (or Patient Centred Medical Homes – to local needs and priorities. However, this needs to be
PCMH), there should be a review (in partnership with approached carefully, to ensure that the outcome is not
consumers) of the implementation and regulatory simply a diversion of primary health care funds to the
requirements for the current trial of HCHs to acute care sector to support hospital budgets which
understand the challenges which have limited take- inevitably come under pressure.
up and impact to date. Rather the aim should be to relieve that pressure and to
support a focus on prevention and integrated primary
• Phase 2 roll-out of HCHs should be commenced,
health care where people are kept well and functioning
with greater flexibility in the funding and delivery
within the community and their own homes as much
model, including adoption of the principles from
as possible, with outreach support from hospitals and
the report, Patient-centred Health Care Homes in
specialised sub-acute, and community health services.
Australia – Towards Successful Implementation. This
phase should provide significantly enhanced access The objectives are obvious. Such a model overcomes
to HCHs, both across primary health care services perverse incentives in funding arrangements and
8 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018promotes continuity and integration of care. While and PHNs as an enabler to assist achievement of
Medicare fee for service and PBS arrangements the COAG National Health Reform Agreement to
through community and hospital pharmacies would be cooperate and coordinate on primary care reform. This
preserved, it would begin to reduce fragmentation and cooperation and coordination are essential if Australia is
competition between the Commonwealth and states to truly establish a consumer centred health system.
and territories. It also promotes increased efficiency This move to formal, four-way sets of agreements
and effectiveness. recognises that LHNs (or their equivalents) should be a
It creates the environment to develop an increased core partner in these arrangements, and not be at arm’s
emphasis on prevention that integrates risk assessment length so that their association with the Commonwealth
across health and social care, with healthcare delivered or with PHNs is via states and territories.
in the most appropriate setting for the consumer. It All integration is local – it cannot be easily imposed from
enables the removal of barriers which prevent people either the national or state level. There are examples
from having choice about where and how their of promising local cooperation and coordination
healthcare is delivered in the most appropriate setting developing between PHNs and LHNs. But these are
for them. not consistent and the development of formalised
It also enables what has been termed the “missing agreements with the imprimatur of governments will
middle” to be straddled – the gap between what primary lay the ground rules in relation to expectations of
health care does now and the interface with the acute cooperation, coordination and integration.
and emergency sectors. With joined up funding and These agreements need to recognise the special needs
clear pathways, and a clear focus on strengthened of those who are disadvantaged, at risk, or who are
primary health care, providers can be supported to work challenged to access the right services at the right
at top of scope of practice, supported by specialised time. This includes Aboriginal and Torres Strait Islander
services, and that gap – which consumers often fall people, people from culturally and linguistically diverse
through – can be bridged. communities (CALD), those living in rural and remote
Fundamental to the model is good governance areas and those with low household incomes. They also
arrangements, including a strong role for consumers need to address the vital role of carers and volunteers in
and clinicians, with systems not only designed to include the health and social care systems.
codesign with consumers and clinicians, but where
Boards and management are contractually required to This overarching priority builds on other
demonstrate that codesign. recommendations in Appendix, Table 1:
• Recognising the role of information as a fundamental
This overarching priority builds on other integration tool, develop a national data set and
recommendations in Appendix, Table 1: performance framework for primary health care
• Transition from largely fee for service general practice to measure impact and outcome of services. Data
to a more flexible funding model based on needs should be collected and used for clearly specified
and outcomes, rather than occasions of service. purposes, including to inform needs analysis and
Over time, consider including these funds in regional planning, enable measurement and analysis of
budgets. performance, and enhance patient management.
• Invest in creating inter and intra professional teams,
Create regional solutions
enabling the workforce that is needed to work best
3. Establish formal Agreements between the in this model of care and for every team member to
Commonwealth, the states and territories, Primary work to full scope of practice.
Health Networks (PHNs) and Local Hospital
Networks (LHNs) (or their equivalent) to improve 4. Progressively empower PHNs to take greater
local and regional system performance and deliver responsibility and accountability for creating
integrated, consumer centred services. primary health care systems in their local areas.
This includes broadening the objectives of PHNs
There have been previous calls for Tripartite Agreements and devolving additional funds from the national
between the Commonwealth, the states and territories,
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 9level to PHNs, with greater flexibility, authority any local or regional services. Choosing an alternative
and accountability to commission services based approach weakens their capacity to leverage change
on population health needs and with consumer and, where there is an exception, there should be a
codesign models supported to share decision- very strong and transparent case for that exception.
making. Progressively, the devolution of appropriate family and
children’s, aged care and other social services to PHNs
PHNs have been established as commissioners of should be considered for integrated health and social
services – the glue that aims to bind the various care commissioning.
pieces of the primary health care system together and
interfaces with the acute sector. They are funded by the 5. Require PHNs and LHNs to work together as co-
Australian Government to increase the efficiency and commissioners of services, to design and develop
effectiveness of medical services for patients, particularly alliance contracting arrangements where desired
those at risk of poor health outcomes, and to improve outcomes are specified and service providers are
the coordination of care to ensure patients receive the incentivised to work as partners in achieving those
right care in the right place at the right time. outcomes.
The establishment of PHNs was an important initiative in
A key requirement of the quadripartite agreements
aiming to rebalance the health system towards stronger
should be a commitment by PHNs and LHNs to work
prevention and primary health care. This recognised
together – with governance arrangements ensuring
the imbalance between state and territory hospital and
partnership with consumers – to plan, design, and
health services, and the thousands of what are generally
commission services which are whole of person focused
small business owners – general practices, pharmacists,
and which make a consumer’s pathway through the
dentists and allied health professionals, for example –
health and social care systems seamless. The consumer
working in the primary care sector.
should not have to worry about who funds and owns
While there are significant expectations about what the various services they need, and nor should they have
PHNs should do, PHNs have limited budgets and limited to tell their story to a variety of different providers. The
control to be able to meet these expectations. Unlike PHN commissioning processes and decisions, including
state-owned and run hospitals who manage their any co-commissioning with other agencies, should
own budgets, for example, most primary care funding involve consumers. This should include steps to ensure
does not go directly to PHNs (e.g. Medicare Benefits, consumers insights and advice is captured in the needs
Pharmaceutical Benefits) but rather subsidises patients assessment phase, service design and evaluation phases.
attending many thousands of independent private It should also involve consumers in funding decisions
providers – general practices and pharmacies. They about services to be funded. Systemic involvement of
also have limited authority and are subject to significant consumers in commissioning carries an obligation on
restrictions and controls on their flexibility to act locally. PHNs to equip consumers with the skills and knowledge
The roundtable strongly supported the role of PHNs and to be able to fulfill these roles well.
the vital importance of their role in working to rebalance Alliance contracting has been a feature of regional
the health system towards prevention and integrated funds pooling in NZ from 2013 . It facilitates the bringing
primary health care. However, it was considered that together of clinical and executive leaders from DHBs,
PHNs needed to be given stronger levers to effectively PHOs and other local services around ‘whole of system’
influence and change the system. service delivery. It focuses on addressing the ‘wicked
This includes a mandate to broaden their scope to problems’ of service delivery at local level especially
enable greater focus on health promotion and illness gaps in services, health inequity, and opportunities to
prevention, backed by adequate funding, devolution of better integrate services around community /primary
all Commonwealth programs (and funding) so that they care delivery and could serve as a model to consider in
are run locally, and increased autonomy so that they are Australia.
truly accountable to their local communities.
This overarching priority builds on other
PHNs should be designated as the first choice for any
recommendations in Appendix, Table 1:
increases in funding by the Commonwealth towards
• Provide additional funding to enable implementation
10 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018of the Productivity Commission recommendation to range of high quality consumer health literacy,
establish “Funding pools for Local Hospital Networks self-management, shared decision-making tools
and Primary Health Networks to use for preventive and other resources to empower consumers to
care and management of chronic conditions at the better engage and participate in decisions about
regional level.” themselves, their families and other support people,
• Agreements should be underpinned by clear the services they receive and the systems they
principles which build a consumer centred system connect with.
and a whole of person approach – recognising
Consumers continue to report a significant power
and responding to the evidence of the strong links
imbalance with providers of services, including in
between physical, mental, social and emotional
communications with GPs and other primary health
health and wellbeing.
care providers. In many cases, this is not seen as
Create regional solutions deliberate – generally there has been an improvement in
communication and in endeavours to ensure consumers
6. Implement a major demonstration project to
are engaged as equals.
measure the impact of empowering consumers with
complex chronic diseases to plan and manage their However, Australia currently has relatively low rates of
health by providing them with flexible individual health literacy and high rates of preventable chronic
funding packages – personalised budgets – where diseases. Patients seek help for their conditions later and
they have choice of services and providers (similar are less likely to self-manage well and comply with their
to the NDIS and aged care reforms). treatment and medications.
The recognition of the need for consumers to be
Personalised budgets can provide empowerment and regarded as partners in care, supported by shared
choice for consumers who often feel they are being decision-making practices is reasonable in Australia,
directed to a service or services with little choice. This bolstered by measures such as the National Safety and
is particularly the case for people with chronic and Quality Health Service Standards. There has been some
complex illnesses who may require a significant number leadership notably from the ACSQHC, some state-based
of providers in both the primary and secondary service agencies such as the Agency for Clinical Innovation,
systems. and NPS MedicineWise’s stewardship of Choosing
The NDIS and aged care reforms provide models of Wisely Australia, however efforts are patchy and poorly
personalised budgets where the locus of control is being coordinated. The problem is not so much that resources
switched from the provider of services to the consumer don’t exist, it is that consumers are not given clear ‘sign
of those services. In implementation, they have had posts’ about how to find and use them. A single point of
their challenges, but the principles of those models have access is missing.
strong support across society. Specific programs need to be put in place and taken
Such an arrangement will not be for everyone and any up to measure and build health literacy and enable
such model needs to be consulted and communicated consumers to engage and participate effectively
clearly. Feasibly it is a model which should be able to be – for themselves, their families and other support
codesigned with consumers and involving a substantial people (including carers), but also with services and
trial by 2023. systems. Health literacy funding should recognise
varying need, for example costs are likely to be higher
This overarching priority builds on other
in disadvantaged communities and those with high
recommendations in Appendix, Table 1:
numbers of CALD people in their populations. There are
• Fund care coordinators or case navigators (via many such programs already in existence. These include
PHNs) in hubs within regional/local settings with Choosing Wisely Australia’s Five Questions to Ask Your
responsibility for ensuring people at high risk can Doctor and the ACSQHC question builder tool.
access health and social services.
Effective integrated care models also need the support
7. Fund a Consumer Enablement Portal to bring of consumers with informed decision making if they are
together and better promote access to a broad to contribute to planning and governance, with trust and
respect from all parties.
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 11When consumers move between services or care feedback “en masse” on issues and improvements
settings there should be a plan in place for what needed, with a focus on their experience of service.
happens next and proactive follow up of the plan. The • Build in funding as standard features in tender and
plan should include medical services and follow-up as contracts to recognise and support the additional
well as referral to a range of other supports designed to costs associated in undertaking effective consumer
help people function as a contributing member of the engagement and participation, as well as recognition
community. of the extra time which proper codesign processes
will take to achieve optimum results.
This overarching priority builds on other
recommendations in Appendix, Table 1: Link up the system
• Enhance competency in consumer enablement 8. Recognising the importance of professional
strategies for health providers by embedding collaboration and team-based care within care
learning of these skills inside education, training and settings and across primary, secondary and
continuing professional development. tertiary health care, introduce funding models
• Ensure consumers are engaged in codesign of which promote joined up models of health service
policies and services and are equal partners in delivery, including incentives which:
evaluation of services.
• Appropriately support engagement of non-
• Involve consumers in governance arrangements
prescribing pharmacists in general practice
throughout all levels of health care.
• Establish GP Liaison Officers in all metropolitan and
• Mandate that funding and contractual arrangements
regional settings
from government to service providers must include
performance reporting and indicators for evidence of • Promote hospital-based specialists providing liaison,
effective engagement with consumers in codesign, advice, support and clinics within general practice
monitoring and reporting. based on community need
• Fund scholarships, bursaries and programs which • Significantly expand access to care coordinators,
support people from diverse backgrounds to develop health system navigators and health coaches on the
the skills and competencies they need to operate as basis of need and region for those with complex
equals in engagement and participation in services, chronic conditions
settings and systems. • Increase the numbers of Aboriginal and Torres Strait
• Require health services to develop structures Islander and CALD people at all levels of the health
and processes which educate Boards, CEOs, workforce,
managers and clinicians on the value of consumer • Promote development, professionalisation and
experiences as essential skills to be built in and employment of a peer workforce with lived
developed alongside other skills such as leadership, experience, with priority for mental health and suicide
finance, human resource management, strategy prevention peer workers.
development, governance and risk management.
Workforce design, development and deployment are
• Require services to budget for and organise major building blocks in any health system change
appropriate training and continuous development agenda. Strong, integrated primary care is only possible
with consumers so that consumers can participate where that workforce collaborates around the needs of
effectively and as equals in corporate and clinical individuals, families and communities.
governance, including training in health literacy.
In turn, services should engage consumers to This recommendation identifies a series of vital steps in
educate them on consumer service experience and developing a team-based, interprofessional approach:
opportunities for improvement.
• Pharmacists
• Require services and systems to utilise a broad range
of digital opportunities to engage consumers and From 1 July 2019, a new Workforce Incentive Program
enable them to express views and provide advice and will streamline existing GP, nursing and allied health
incentive programs, replacing the General Practice Rural
12 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018Incentive Program and the Practice Nurse Incentive receive duplicated and therefore wasteful services, and
Program (PNIP). There will be two streams – a Practice can end up requiring what could have been avoidable
Stream and a Doctor Stream – and for the first-time hospitalisations. Care coordinators, navigators and
general practices will be able to access incentive coaches can all help overcome these problems and
payments of up to $125,000 a year (plus potentially a should be deployed in hubs throughout Australia
rural loading) to employ non-dispensing pharmacists. (general practices, Aboriginal Community Controlled
However, employment of pharmacists will be in Health Services and rural hospitals) as needed.
competition with existing incentives to employ practice
• Aboriginal and Torres Strait Islander health
nurses and allied health practitioners (already available
workforce
under PNIP).
Significant efforts have been made to increase the
The inclusion of pharmacists within general practice
numbers of Aboriginal and Torres Strait Islander people
brings benefits for patients in terms of better medicines
in a range of health professional areas. However,
management, and to the system through better use of
there remains a large gap in achieving a sufficiently
medicines and reduced adverse events. To speed up the
representative workforce and an under-recognition
desirable inclusion of pharmacists within practices, the
of the diverse roles played by Aboriginal and Torres
Australian Government should dedicate a component
Strait Islander health professionals in the delivery of
of the professional services program under future
comprehensive primary and integrated health care
Community Pharmacy Agreements to support models
services.
of care that integrate general practice and pharmacy
services, and fund general practices (through increased Work should be undertaken by governments in close
funding of the Workforce Incentive Program or through collaboration with Aboriginal and Torres Strait Islander
PHNs) as an incentive to employ non-dispensing organisations to identify the shortfall in Aboriginal and
pharmacists. Torres Strait Islander workers needed across the health
sector and clear policy targets and implementation
• General Practice Liaison Officers plans should be set to address the gap in workforce
GPLOs play an important role in enabling better participation.
coordination, communication, discharge planning and
• Peer workers
handover to and from hospital and general practice/
community settings – an area of notorious challenge The importance of peer-workers engaging and
over decades within the Australian health system. They supporting people in the health system is becoming
should be supported by LHNs and PHNs to operate in all increasingly well recognised. The number and breadth
metropolitan and regional hospitals. of role of peer workers continues to expand, albeit not
consistently across Australia – the recognition of peer
• Hospital based specialists providing community workers as vital professionals is still in its developmental
outreach stages.
If GPs, nurses and allied health professionals are to The variation in the definition, accountabilities and roles
operate at the top of their scope of practice, and support of the peer workforce is a barrier to the inclusion of peer
people to remain active in the community instead of workers as formal members of the multidisciplinary
having to seek specialist hospital care, they need to team and therefore limits the valuable contribution they
be supported by specialists who can assist them with can make to improving health care delivery.
patients with higher acuity, severity or complexity. Supporting the growth and recognition of the peer
Funding mechanisms are required which support this workforce as an emerging profession is seen as a vital
approach. cog, particularly in mental health and suicide prevention,
but also in other areas e.g. cancer services, diabetes
• Care coordinators, health system navigators and
management. Peer workers can add significant value
health coaches
to the multidisciplinary team, for example by including
People with complex needs often face great difficulty them in Emergency Departments to assist in de-
in navigating the health system, fall through the gaps escalation of trauma for people who attend with acute
in the system, go without necessary services, can or manic episodes, and by “walking with” and following
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 13Snakes & Ladders
up with people who are discharged from hospital after a in the health system. What a provider views as a good
suicide attempt. patient outcome may not necessarily align with the
These workforce enhancements will not occur quickly views of a consumer – e.g. an exclusive focus on ‘getting
by simple policy decisions and recognition of the better’ may come at the expense of poor experiences of
desirability of change. Rather they require commitment care and treatment, potentially demeaning health care,
backed up by additional funding as incentives for and mean lower quality of life according to what the
desirable change. consumer values.
There is a growing awareness that clinical outcomes
9. Recognise the important role of primary health alone are not a sufficient measure of system
care information – including patient experience performance as patient perceptions often differ from
measures - as fundamental to better patient clinicians’ assessments. Patient reported outcomes
management, service development and quality and experiences can be used to inform the interaction
improvement, integration, and accountability. between patients and provider but are also a valuable
Scope and develop a primary health care component of population health surveillance at a
information strategy that includes: broader level and can inform policy and service design
• A national minimum data set and performance decisions.
framework for primary health care to measure impact Mandating measurement and reporting of consumer
and outcome of services experience will provide valuable information that will
• Mandated measurement and reporting of consumer inform design, development and delivery of services,
experience through Local Hospital Networks, Primary will lead to more efficient and effective services, and
Health Networks and the services they fund as greater satisfaction for both consumers and services –
important measures of better health outcomes and the Quadruple Aim to achieve a high performing health
better experience of care. Link organisational funding system.
and Board Director and management performance
Lead into the future
contracts contracts/agreements to achievement of
10.Invest in the establishment of a government-led
standards on consumer engagement and experience
National Centre for Health Care Innovation and
Primary health care information should not sit in Improvement. The centre would support system
isolation of the broader health system, but rather it stewardship by testing and scaling up new models
should be viewed as an essential component, which of care and payment systems that work for patients,
when linked with other data sets, can enable a whole of build capacity in the commissioning work of PHNs
person/service/setting/systems approach. and their co-operation with LHNs, and spearhead
The first priority in developing a minimum data set national efforts to support the development of
should be to clarify its purpose – its intended use. clinical and consumer skills in leadership, change
Consumers often feel that data are collected for management and improvement science. The centre
purposes unknown and potentially not used – there is should be a private-public partnership involving
lack of transparency. Data collections should have clearly clinical, consumer, academic and industry leaders
specified purposes, including to inform needs analysis and philanthropic funding.
and planning, enable measurement and analysis of Many of the policy settings and new directions needed
performance, and enhance patient management. to drive transformational reform for better integrated and
Data collection should include use of tools which coordinated primary health care have been identified
measure consumer experience and which already exist, and documented. However, gaps exist between policy
such as patient- reported experience (PREMs), patient- commitment and the implementation and translation of
reported outcomes (PROMs), and Your Experience of policy intent into changed systems and services. There
Service (YES). have been many attempts to reform the health system
Consumer experience of service is increasingly being and numerous ideas have either failed or faltered during
shown to be fundamental to achieving good outcomes the implementation process.
14 Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018The evidence is clear: investment in change and of ensuring innovation, quality, safety and value in
change management expertise and capability in the health care. In the UK, various modernisation and
system is needed if implementation is to be effective quality agencies have been established to help drive
and sustained, with broad support and adoption from transformation of health care.
stakeholders. In Australia no such national agencies to steward
There is much we already know about the change, innovation and improvement exist. We have
circumstances that can determine whether changes the Australian Commission for Safety and Quality in
in the health system succeed or fail. Policy mandated Healthcare, and state level agencies such as Safer Care
change in a complex health system is unlikely to effect Victoria and the NSW Centre for Clinical Excellence, all
change, while clinically or evidence-based change of which have a primary focus on promoting quality and
might. Local innovation from within the system is far safety in hospitals settings. They do not have a wider,
more likely to succeed than a decision coming from whole-of-health system purview. Australia also has had
outside the system. Change is accepted when people forums focused on supporting leadership such as the
are involved in the decisions and activities that affect National Lead Clinicians Group which have not been
them, but they resist when change is imposed by sustained, and there are current demonstration initiatives
others (Braithwaite, 2018). In Scotland, for example, of innovative ways for consumers and clinicians to
reports have found that national mandates for change, learn and lead together such as the Collaborative Pairs
but implementation driven locally through shared Australia demonstration project being coordinated
funding, risk and accountability translated into better by CHF, which test out this joint leadership program
collaboration between sectors of the health and social initiated by the UK Kings Fund in the Australian context.
systems who may not have worked together in the past An overarching centre with the mandate to drive change
(Bayliss and Trimble, 2018). This final recommendation could both house, support, further develop and sustain
will assist in building PHN capacity to research and such forays.
economically evaluate local needs in their work Australia needs to develop a national model to support
identifying and commissioning services. health system wide transformation which is fit-for-
Our ten recommendations are based on evidence and purpose for our unique circumstances and systems.
where expert opinion of roundtable participants and Various options could be explored that could help build
other authoritative commentators, most recently the rapid implementation and translation capability including
Productivity Commission, believe we have opportunity the feasibility of partnering with global organisations
to innovate. They also are based on lessons and with the desired expertise such as the Institute for
observations made about how Australia has gone about Healthcare Improvement (IHI). A centre such as the one
implementing precursor or current reforms such as the proposed here would take a ‘start up’ approach to health
coordinated care trials, the trial of HCHs and introducing care innovation heavily backed by its principal investor:
My Health Record. the Australian public.
However, as with any ambitious agenda, we are Consumer empowerment and clinician leadership
experimenting with change as much as any country and is needed to support and enable political and other
therefore there is strong need to nurture a culture of leaders to design and implement models which support
innovation and put in place sound frameworks to learn transformational change and a stronger, integrated
along the way. primary health care system. The invitation is open.
As one group of US researchers put it: primary care
practice transformation is hard work. They describe the
complex nature of primary care practices, the challenges Knowing is not enough;
of introducing change and quality improvement and the we must apply.
scale and nature of the change required to move models
of care to the idealised vision of the patient centred Willing is not enough;
medical home. we must do”
In the US the National Academy of Medicine describes
- Goethe
the concept of a learning health system as a means
Snakes & Ladders: The Journey to Primary Care Integration
A health policy report – September 2018 15Where to next?
Australia requires accelerated action on primary care • Power and control
reform to reduce current strains on the health system. • Ownership of the change
It is well established that the drivers of such change
• Workforce design and scope of practice
depends on a range of factors:
• History of the system in which change is being
• Funding incentives
implemented and the associated willingness to do
• Data and benchmarking, particularly where there are something differently
clear reporting and accountability arrangements
• The health system environment
• The reward system
• Evidence
A strong primary health care system is fundamental to increasing efficiency, reducing hospitalisations, lowering health
inequalities and ultimately improving health outcomes for all Australians. The recommendations in this report outline
the right settings for system change, critical to transform our health system and strengthen consumer-centred and
community-based primary health services for generations to come. The report recommendations can be distilled
into 14 key elements needed to create a model for transformation and implementation:
Consumer empowerment in their own care
Common objectives
and system engagement
Shared long-term vision among stakeholders
Consumer centred system
Clinician leadership Joint planning and alliance contracting
Clinicians using evidence to embrace and drive Between Commonwealth, states, territories,
change PHNs and LHNs
PHNs with authority and funding levers Technologically enabled
Increased funding, accountability and autonomy Data and digitally driven
Integrated models of care
Prevention and primary health care led
Health Care Homes V2, rewards for
Reorient the system for better access,
innovation and linkage with all relevant
effectiveness and efficiency
providers
Regional budgets
Codesign with consumers and clinicians
Fund pooling with consumer informed outcomes
To go further, go together
and involvement
Funding models reward outcomes not activity
Funding certainty
Broader funding models and reduced perverse
Use a 3-5 year horizon
incentives
Investment in implementation and
Communicate, communicate, communicate
innovation
A clear and transparent engagement strategy
Sustained, persistent and properly funded
16 Snakes & Ladders: The Journey to Primary Care Integration
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