Primary Care Reform at a Crossroads: Using Polarity Management to Find a Way Forward

Paresh Dawda

Australia’s 2025 federal election campaign has placed primary healthcare firmly in the spotlight. Both major parties – the Australian Labour Party (ALP) and the Liberal Party – have promised over $8 billion in funding, with initiatives such as building new Urgent Care Clinics and boosting bulk billing incentives.

The ALP’s policy, claiming 90% of general practice patients will be bulk billed under a "triple bulk billing incentive," has sparked debate. While this offers a politically attractive message of ‘free care’, many in the profession are raising the alarm: for numerous practices, especially those already struggling under cost pressures, this model risks financial unsustainability if they were to shift to bulk billing.

Rather than deepening this polarisation, Polarity Management principles offer a path to a richer conversation — and potentially a smarter use of the multi-billion dollar investment opportunity for modernising primary care.

Understanding Polarity Management

Polarity Management (developed by Barry Johnson) recognises that many persistent problems are not problems to "solve" with an either/or answer. Instead, they are polarities to manage — ongoing tensions between two interdependent values, both of which are necessary for long-term success.

Key concepts:

• Poles: Two sides of a tension (e.g., Accessibility vs Financial Sustainability in healthcare).

• Upsides and Downsides: Each pole has benefits (upsides) and risks (downsides) if overemphasised.

• Dynamic Balance: Effective leadership doesn't choose one pole over the other but continually balances them.

Applying Polarity Management to Australia's Primary Care Debate

The current debate is being framed simplistically:

• More bulk billing = Good

• Less bulk billing = Bad

But the deeper polarity is:

Pole 1	Pole 2
Bulk-billing for the majority for primary care general practice visits (90%)	Primary Care Financial Sustainability and Quality

Both are vital:

• Without (affordable) accessibility, healthcare becomes inequitable.

• Without financial viability, there are no practices left to provide care or perverse incentives drive low value care.

	Pole 1: Bulk-billing 90%	Pole 2: Financial Sustainability (Viable General Practice) and quality
Upsides	Equitable access for all Australians, prevention of health disparities	High-quality, resilient primary care workforce, innovation, continuity of care
Downsides if Overemphasised	Unsustainable practice costs, workforce exits, collapse of independent practice	Care becomes unaffordable, vulnerable patients miss out, worsening health inequalities

Indicators We're Managing Well

High patient satisfaction and practice viability indicators; GP workforce growth; quality indicators improving

If we overfocus only on accessibility (without regard for financial realities), we risk:

• Practice closures

• Workforce burnout

• Reduced quality of care

If we overfocus only on financial sustainability (without commitment to accessibility), we risk:

• Exclusion of vulnerable groups

• Widening health inequities

  
  

Polarity management teaches that both are true and both must be protected.

Reframing the Real Question

Current discussions orbit obsessively around bulk billing rates. But bulk billing is just a mechanism — not the goal.

The real question should be: Should primary care in Australia be free (or virtually free) at the point of delivery?

Should primary care in Australia be free (or virtually free) at the point of delivery?

• Yes
• No

If yes, then what is the sustainable funding model to enable that, ensuring practices can provide quality care without financial risk or burnout?

If no, then how do we fairly structure patient contributions, balancing access, affordability, and sustainability?

Dodging this deeper conversation traps us in a perpetual loop of tweaking rebates without addressing the underlying contradictions.

Suggestions for Managing the Polarity

Using Polarity Management principles, a way forward could include:

Element	Supporting Access	Supporting Sustainability
Policy Language	Commit to universal, affordable access in principle, without tying it only to bulk billing.	Commit to viable practice models with adequate base funding for services delivered.
Funding Structure	Targeted incentives for vulnerable groups (e.g., children, pensioners, healthcare card holders)	Mixed funding models: appropriate rebates for standard patients, with flexible patient contributions.
Workforce Support	Invest in community-based services (social work, mental health) around GPs to support patients’ needs.	Invest in GP grants and incentives for training practices, team-based care, and chronic disease management.
Measurement	Focus on measuring access outcomes (waiting times, barriers to care).	Focus on quality and outcome measures, not just service volume.

Rethinking the Multi-Billion Investment: Options for a Contemporary and Progressive Primary Care System

Instead of funnelling the billions of dollars promised primarily into urgent care clinics and bulk billing rebates, consider diversifying the investment to build progressive, consistent, and contemporary models.

Focus Area	Current Mechanism and How to Strengthen	New Funding Mechanism Proposed	International Example	Other Relevant Commentary
Core Practice Funding	Fee-for-service (MBS billing); some incentive payments (e.g., PIP, WIP). Strengthen: Introduce base infrastructure grants and minimum guaranteed funding per practice.	Establish a Core Funding Package (base bundled-style funding per practice linked to patient enrolment and quality improvement activity).	UK: NHS Core Primary Care Contract funding for GP practices. New Zealand: PHO capitation payments.	Enables continuity, infrastructure investment, and strategic planning without solely chasing activity volume.
Team-Based Care Models	Separate funding streams (e.g., Workforce Incentive Program); limited team-based payments. Strengthen: Expand eligibility for funding across team roles, not just GP-centric.	Fund Primary Care Teams (GPs, nurses, allied health, pharmacy, mental health) through bundled payments per enrolled population.	Canada: Ontario Family Health Teams funded via capitation + team funding.	Facilitates integrated, patient-centred care and manages rising chronic disease burden.
Health Equity and Social Determinants Initiatives	Little to no targeted funding for social determinants at practice level. Strengthen: Expand targeted rural loadings and Indigenous-specific grants.	Create Health Equity Funds for practices serving low-SES, remote, and disadvantaged populations.	USA: Medicaid DSRIP (Delivery System Reform Incentive Payment) programs incentivising social determinants integration.	Reduces health inequities and improves long-term health system sustainability.
Outcome-Based Funding Trials	Pay-for-service only with some pilot outcomes-based trials (e.g., Health Care Homes). Strengthen: Broaden pilots, include meaningful patient-reported outcomes.	Implement Outcome-Based Funding Models linked to clinical outcomes and patient experience (e.g., diabetes control, cancer screening rates).	Sweden: Stockholm’s outcomes-based reimbursement for chronic conditions. Netherlands: Bundled payments for diabetes care.	Encourages focus on prevention, quality, and patient-centred care rather than volume alone.
Primary Care Innovation Fund	Research support through grants (e.g., MRFF), but limited practice-based innovation funding. Strengthen: Allocate dedicated funds for primary care innovation.	Create a Practice-Based Research and Innovation Fund to support real-world trials and quality improvement within general practices.	USA: PCORI (Patient-Centered Outcomes Research Institute) supports pragmatic trials in primary care.	Empowers frontline practices to innovate, evaluate and spread new models that work locally.
Digital Transformation Investment	My Health Record and Practice Incentives (e.g., ePIP); largely fragmented support. Strengthen: Incentivise true interoperability and system usability.	Fund Digital Transformation Grants for EMR upgrades, real-time data analytics, telehealth infrastructure, and integrated care tools.	Denmark: National strategy for interoperable primary care digital records; high GP adoption rates.	Enables proactive, data-driven, population health management models.
Fund Enrolled Patient Models	MyMedicare voluntary patient registration; some Health Care Homes pilots (now ended).	Expand MyMedicare nationally with risk-adjusted bundled payments; tie enrolment to care planning, preventative services, and quality outcomes.	United Kingdom (NHS GP Patient Registration + QOF), New Zealand (Primary Health Organisations), Canada (Patient Enrolment Models in Ontario).

Conclusion: A Better Way Forward

Australia’s next decade of healthcare reform cannot be built on polarised slogans about bulk billing rates alone.

True reform requires:

• Managing polarities, not picking sides.

• Building models that deliver universal access and practice sustainability.

• Aligning investment to new models of care, not patching up old systems.

The additional promised investment in primary care is welcome, but the opportunity in primary care is not just about spending — it’s about building the foundation for a healthier, more equitable, and sustainable Australia.

Leadership will be judged not by promises made — but by tensions wisely managed.