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Strengthening Medicare Taskforce: How to modernise primary health care
By Mary Chiarella AM, Professor Emerita, Susan Wakil School of Nursing, University of Sydney , and APNA CEO Ken Griffin
Source: APNA Primary Times Summer 2022-23 (Volume 22, Issue 2)
Following the outcome of the 2022 federal election, Health and Aged Care Minister Mark Butler convened the Strengthening Medicare Taskforce (SMT), which seeks to improve access to affordable quality primary care for all Australians. The Department identifies the SMT’s aims and focus areas on its website.i,ii Here, we share some thoughts about how its goals might best be achieved.
Building and retaining a strong workforce
The first of the five focus areas identified by the SMT is to have ‘a reliable training and development pipeline, to build a strong and vibrant primary health care workforce.’2 This is a logical and critical step. However, to plan for a strong workforce, we first need to determine exactly what kind of health care the Australian community needs.
The roles played by primary health care (PHC) nurses and allied health professionals are crucial in keeping people functional and independent, but neither sector has been adequately planned for. The Chief Nursing and Midwifery Officer and Chief Allied Health Officer are currently developing respective workforce strategies; but both are under-resourced, and their timeframes are uncertain. The SMT needs to consider how its recommendations will interact with these strategies to achieve a health workforce that can provide the required capabilities.
In addition to workforce planning, a PHC training and development pipeline will rely on strengthening the presence of PHC in the undergraduate curriculum and funding PHC student placements for the next generation of PHC health professionals.
Once we have trained and attracted a strong workforce, we need to ensure that the careers of PHC professionals are sustainable and satisfying. Value-based care is best delivered by health-care professionals working in multidisciplinary teams to their top scope of practice. This generally results in better patient outcomes and is particularly needed in general practice and rural health settings.
Many GPs report that they are overworked and underpaid. At the same time, PHC nurses are often not working to their full scope, and many are planning to leave the profession. There is still time to prevent this. We need to teach GPs and practice managers to utilise the nursing and allied health workforces better. This can be turbo-charged by reviewing funding models and Medicare item descriptors and increasing accountability for workforce incentive payments.
A fundamental shift in the use of nurse practitioners (NPs) in PHC is also required. Despite their extensive skill set and training, this group has faced ongoing exclusion from PHC funding and restrictions on their autonomy. If we want to improve Australia’s health, we need to start maximising the potential of NPs in PHC. The same could be said of many other specialised PHC nurses, particularly Australia’s highly trained mental health nurses.
The SMT’s second aim is ‘improving patient access to GP-led multidisciplinary team care, including nursing and allied health’.1
Multidisciplinary team care is essential and already present in the existing PHC models. However, why has the SMT specified that this team-based care needs to be exclusively GP-led? Whilst in many instances GPs are the centrepiece of primary medical care, it is not accurate to suggest that they are always the centrepiece of primary health care.
Australia’s GP shortage is set to increase, and alternative models of care are well underway. APNA’s nurse-led clinic model has been going strong for almost a decade and the positive benefits include improved patient health outcomes, better access to care, and decreased rates of hospital admission. Many communities are served almost exclusively by nurses using different models of care (e.g., Aboriginal Community Controlled Health Organisations, corrective and justice services, midwifery services and nurse triage telehealth programs).
APNA’s nurse-led clinic model has been going strong for almost a decade and the positive benefits include improved patient health outcomes, better access to care, and decreased rates of hospital admission
This approach can also be applied to other underutilised health workforces. A range of models have been suggested where allied health professionals can also lead a multidisciplinary team.
It’s true that multidisciplinary care can produce stronger patient outcomes; but the SMT’s emphasis on GP-led models seems to be at odds with the need to re-envisage PHC. If the aim for the future is to unlock the potential of all PHC practitioners and to improve access and equity for all Australians, we need to look forward and consider a broader range of more flexible health-care models.
Team-based multidisciplinary care
The third focus area of the SMT is ‘Increased access to multidisciplinary care, harnessing the full skills of nurses, pharmacists and allied health professionals.’2
As noted above, health care is a team game, and a patient is best served when every discipline within that team can fully play their part. Multidisciplinary care has been shown time and again to provide high patient engagement, strong patient outcomes and higher worker satisfaction.
The politics of health care tends to follow the idea that care is about ‘either/or’. For example, a nurse practitioner OR a general practitioner must diagnose a patient. However, the reality of modern health care is that professionals with different areas of speciality, knowledge and expertise are complementary to each other’s work. Working as a team generally results in better care and outcomes for the patient.
The reality of modern health care is that professionals with different areas of speciality, knowledge and expertise are complementary to each other’s work.
Unfortunately, some health professionals haven’t traditionally been taught to work in teams and this division is then reinforced by funding systems. Better team-based care practices could be reinforced by directing professional development funding into team-based training, reviewing funding models to incentivise team-based care, or updating current health care curricula to enhance team-based work in PHC settings.
It is time to recognise that working with other funders and owners of general practices is required. Lobbying efforts on behalf of general practice owners have left the Australian public with the misguided impression that GPs must be the employers and controllers of all other professions within general practice. However, this is not the case. For the past decade, the APNA Workforce Survey has shown that ~40% of nurses are never or rarely used to their full scope of practice. This is a ridiculous waste of potential and professional expertise.
The SMT’s fourth aim is ‘ensuring access to care is modern, patient-centred and easy, harnessing the power of technology.’2
Investment in digital health has been a cautionary tale for most health systems. However, this does not need to be the case. A starting point could be enabling access to appropriate technology by all health professionals. Ensuring all team members have access to necessary hardware, and training on relevant health software and systems is essential to unlocking the full benefits of digital health.
Another option could be ongoing investment and consultation into My Health Record (MHR), supported by strong policy that ensures full use by all health professionals. Currently, very few allied health professionals have access to MHR.
A third possibility would be accelerating the interoperability of clinical software through clear standards for both hospital and PHC software, and to ensure health-care professionals realise the benefits of digital health. These benefits will not be realised if health professionals see digital health as optional, or if government policy continues to exclude them from it.
The use of telehealth is an example of care that could be expanded to improve access, as it can put a health professional in every Australian living room.
The next leap in medicine will see the use of personalised medicines, which will require significant use of diagnostics within PHC and integrated/interoperable systems. Australia’s health systems and the health-care workforce need to be ready for this.
The use of telehealth is an example of care that could be expanded to improve access, as it can put a health professional in every Australian living room. Throughout the COVID-19 pandemic, general practice was able to provide telehealth consultations under the MBS to support patients during lockdowns. Crucially, this was also provided to nurses in general practice. Unfortunately, these temporary MBS telehealth items have since been wound back.
Virtual hospitals are another great innovation. Northern Sydney Local Health District’s Virtual Hospital was set up during COVID and treats patients who are COVID-19 positive in their homes, unless they require a transfer to hospital. Patients can speak to a registered nurse if they have concerns about worsening symptoms or are anxious. Patients are categorised into high, medium and low risk, and each day the team calls them to discuss their symptoms and welfare needs. There is significant support for virtual hospitals to continue.
Equal access to health care for everyone
The SMT’s fifth aim is to provide ‘universal health care and access for all through health care that is inclusive and reduces disadvantage.’1
While Australians are proud of their health-care system, it is well established that ‘where you live, how much you earn, whether you have a disability, your access to services and many other factors can affect your health.’iii
While Australians are proud of their health-care system, it is well established that ‘where you live, how much you earn, whether you have a disability, your access to services and many other factors can affect your health
Planning true universal health care requires recognition of the health issues facing our most marginalised members of society. The Australian Institute of Health and Welfare states that:
Overall, Aboriginal and Torres Strait Islander people, people from areas of socioeconomic disadvantage, people in rural and remote locations, and people with disability experience more health disadvantages than other Australians. These disadvantages can include higher rates of illness and shorter life expectancy.3
Improving access to health care for marginalised groups will require solutions that are tailored to different types of disadvantage. These solutions will rely on detailed, up-to-date data sets that can be used to identify the accessible health workforce in various parts of the country. Many of the initiatives described above (e.g., alternative care models; multidisciplinary care; and maximization of PHC nurses, allied health professionals and NPs) could have a powerful impact on improving access to health care and reducing disadvantage around Australia.
If the Health Minister’s Taskforce is to truly strengthen Medicare, its recommendations must recognise and understand the true needs of the most marginalised members of our society and ensure that when they reach the front door of Australia’s health system, it will always be open.
This article has been adapted for Primary Times from a series of blog posts written for John Menadue’s Pearl and Irritations. For the full series, go to: https://johnmenadue.com/