Ladders & Snakes - Consumers Health Forum of Australia

 
Ladders & Snakes - Consumers Health Forum of Australia
Snakes
                              &Ladders
                                          The Journey to
                                          Primary Care
                                          Integration

A health policy report – September 2018
Ladders & Snakes - Consumers Health Forum of Australia
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
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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
Ladders & Snakes - Consumers Health Forum of Australia
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
Ladders & Snakes - Consumers Health Forum of Australia
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
Ladders & Snakes - Consumers Health Forum of Australia
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   5
5 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 2018
7. 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   7
The 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 2018
promotes 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   9
level 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 2018
of 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   11
When 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 2018
Incentive 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   13
Snakes & 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 2018
The 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   15
Where 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
      A health policy report – September 2018
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