The Health Care System in Australia and the Role of General Practice
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The Health Care System In Australia and the Role of General Practice Winthrop Professor Geoff Riley Acting Dean Faculty of Medicine, Dentistry and Health Sciences The University of Western Australia Email: [email protected] Starting points China has the opportunity to develop the best aspects of western health systems. Comparing Health Systems Expenditure and Indicators Country Health % GDP Life Expectancy Infant Mortality (2009)/ rank (2012)/rank (Deaths/1000 live births) Australia 8.5/47 81.9/9 4.5/189 UK 9.3/41 80.1/30 4.56/188 Canada 10.9/22 81.4/12 4.85/181 US 16.2/2 78.5/51 6.0/173 China 4.6/148 74.8/96 15.6/110 The Australian Health System Tertiary Care − All Australians have the right to free treatment at public hospitals − Large city public (teaching) hospitals and Private hospitals − Salaried Specialist doctors and Tertiary services eg Liver transplant, Emergency services, Specialist outpatient clinics etc. Secondary Care − Specialist doctors in Private practice. Mostly urban. Some rural − Some regular rural visiting but only larger rural towns Primary Care Private General Practice / Generalist – Primary Care - Gatekeeping, Access / point of entry to system – Comprehensive service, Generalist, holistic – Local, community, accessible, contextual, coordination of care – Personal consultation-based (WHO model), Continuity of care Funding the Health System Medical Benefits Scheme (MBS – “Medicare”) Universal health care is provided to Australians through Medicare which funds free hospital treatment and subsidised medical treatment – but gap / co-payment of about 30% for all but the very poor in primary and secondary care. Public hospital care is free. IMedicare is funded through general tax revenue plus a tax levy for high income earners and an additional levy for high income earners who do not have private insurance. Private insurance available. Offers services earlier care (eg operations) or in better facilities, but the quality of the Medicine is the same. Plus other services eg Dentist Pharmaceutical Benefits Scheme (PBS) Provides reliable, timely and affordable access for medications Australian Government through the PBS meets 84% of the total cost of all prescribed pharmaceuticals Primary Care • Definition − Community-based health care which is therefore available, accessible and affordable − Private and public providers − Public health and social determinants of health • Professionals and programmes − General Practitioners and practice nurses − Community Nurse and rural and remote nurses − Allied health professionals in Private practice Primary Care Some examples of Primary Care Services General Practice, General Dental practice, Specialised nursing services (domiciliary aged care, Child development, and immunisation clinics), local Pathology and Radiology services, Physiotherapy, Occupational therapy, Speech pathology, Pharmacy, Mental Health services, Youth Mental Health services, Drug and Alcohol services, Psychologists, Optometry, visiting specialist services, Aboriginal Medical Services, Health education and specialised education eg Diabetes care. Related services – Medicare offices, disability support services, Child protection services, Population Health services, Dept of Community Health and Welfare, financial counselling services and so on. Primary Care Provides Access Access is central to the performance of health care systems around the world and includes the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: approachability; acceptability; availability; affordability; appropriateness and accommodation (flexibility). Levesque et al (2013) Comparing Primary Health Care Systems Outpatients or Polyclinics Models of Primary Care The Non-medical models ‘Bypass’ Comparing Primary Health Care Systems Country Provider Gatekeeping Payment Insurance IT Australia GP Yes FFS Gov + Pat (Gap) Good UK GP Yes Cap/Sal/Inc Gov (NHS) Good Canada GP Incentives FFS/Cap Gov Good US Family Pract/Int /O No FFS Pat (employer) Poor & G/Paed China GP No Sal? ? ? Schoen, C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs and Experiences. Health Affairs (Millwood). 2009;28(6):w1171-83. Why is Primary Care an essential part of the Health System? • Access means more timely care – treatment before more severe problems develop • Fewer preventable emergency department visits and hospital admissions • Avoids unnecessary care – fewer tests, overtreatment, less cost • Better health outcomes – especially for the poor, immunisation, BP control, reduced mortality, and improved quality of life • More preventive services than those who lack this source of care • Increased trust with primary care physician and improved treatment compliance Primary Care enhances the performance of health care systems. It is not the solution to every health-related problem, but few, if any, health related problems can be adequately addressed without it. Phillips, RL and Bazemore, AW 2010 A Better Health System A Health Care System which has General Practice in the Gatekeeping role Common conditions and Acute illness chronic illness, acute illness General Practitioner Ambulance 80% Home Specialist Hospital “Gatekeeping” means mandated referral by GP and no direct access to Specialists A Better Health System A Health Care System which has General Practice in the Gatekeeping role. Primary Care – GP and Patient Secondary Care – Private Specialist Tertiary Care – Hospital Specialist “Gatekeeping” means mandated referral by GP and no direct access to Specialists The Best Health System A Health Care System which has General Practice at its core. Tertiary Care – Hospital Specialist Secondary Care – Private Specialist Primary Care – GP and Patient General Practice in Primary Care Primary Care requires high quality vocationally trained General Practitioners (GP) as it’s core to provide leadership and skilled clinical care GPs provide local, accessible, affordable high quality health care and therefore health care security for local communities, including rural communities Gatekeeping GPs are the coordinators of care and decide who needs to be referred for hospital / specialist services and who can be managed locally This system is the most cost effective (it saves money) and provides the best health outcomes for patients Summary A primary health care system which includes gatekeeping GPs can be best understood as creating an orderly delivery system which by referral connects the correct patient to the correct specialist, thus maximising the most cost effective and efficient use of the Specialist / tertiary services. This save money and produces better outcomes BUT, the GPs have to be highly skilled and therefore highly trained to get these decision right. Accordingly China must develop high quality training for GPs and expect to pay them properly. The Role of General Practice The role of The General Practitioner in a health care system is no more or less important than the role of the Specialist. Each has a distinctive set of knowledge and skills. The General Practitioner is a just different kind of doctor, with a different function in the Health System. The system needs both types of doctor to function effectively. Specialism Generalism The Characteristics of Generalism • “Technical Generalism”, Broad knowledge base • “Evidentiary Generalism” – Use of patients’ knowledge (epistemology) and worldview (ontology) – “meaning”, sociological and cultural awareness, contextual thinking, systems theory, psychological insight • “Reflexive Generalism” – Intentional choosing of generalism, reflection, time, growth of understanding and objective self- awareness, “wisdom” Heath and Sweeney 2006 So what does General Practice look like in Australia? A Typical Day in GP in Australia Standard GPs treat all consultation stages of life 15 minutes Long consultations 35—45 30-50 patients/day minutes Less common and More common Acute Medical Emergency Common conditions and chronic • Road trauma illness (including metal health). • Myocardial infarct And Multi-morbidity - Long term • Infants in respiratory distress management required. Presentations to General Practitioners in Australia National average % Social Male genital system Female genital system Pregnancy & family planning Urology Endocrine & metabolic Skin Respiratory Psychological Neurological Musculoskeletal Circulatory Ear Eye Digestive Blood General & unspecified 0 2 4 6 8 10 12 14 16 18 20 The Nature of General Practice Care Primary Gate keeping Contextual Local Comprehensive Generalism Personal Consultation Continuing Care Long term Coordinated Not fragmented care Consultative style of Practice "Spending time with patients listening to their story and their concerns actually saves money.” “More listening means less referral for tests. The best investigation is the conversation – taking a history, and then examining the patient.” A General Practitioner Undifferentiated Presentations Primary: First point of contact. Gatekeeping. Point of entry to system. Undifferentiated presentations. Requires excellent diagnostic skills. “A 48 yr old female says “Just a quick visit because my muscle therapist sent me to see you as I have a pain in the side of my chest and he thinks I have a broken rib”. History reveals no trauma and local examination reveals point tenderness