Leanne Wells and Paresh Dawda, Prestantia Health
Primary care is the mainstay of health systems yet many countries grapple with how to sustain primary care at the same time as they strive to ensure delivery is safe, high-quality and continues to improve and innovate to respond to people’s evolving needs.
The missing link in primary care reforms
The Strengthening Medicare Taskforce triggered a first wave of reforms designed to modernise Medicare and put it on a more sustainable footing. The report recognised that change management and cultural change will be required to implement ambitious reforms over time. The report offered high-level recommendations under this theme but fell short of specific ideas about how leadership and cultural change could be realised.
A year or so earlier, the Australian Commission on Safety and Quality in Health Care (ACSQHC) launched the National Safety and Quality Primary and Community Health Care Standards laying out three standards which all primary and community healthcare services can apply: clinical governance; partnering with consumers; and clinical safety.
The missing link to tackling these policy ambitions and standards aspirations is a systematic, nationally spearheaded approach to primary health care improvement.
Improvement gives the people best placed to influence quality the time, permission, skills, and resources they need to solve them. It involves systematic, coordinated approaches using specific tools and methods with the aim of bringing about a measurable improvement in the quality of care.
The benefits of improvement to patients, service users and society are wide-reaching, and can include the way care is delivered and the way the system operates. They include improved access to appointments and services; smoother flow between services; care avoidance through earlier diagnosis; improved safety and improved outcomes through reliable adoption of best practices. The same applies to organisations where the benefits range from efficiency gains via removing waste, delay, and duplication to productivity gains from faster technology adoption.
Most importantly, improvement approaches are not just a mechanism for improving care processes and pathways and tacking variation. They are indispensable when it comes to tackling the biggest delivery and transformation challenges that healthcare faces.
Promising improvement forays
Improvement is often well funded in hospitals, with staff trained in evidence-based improvement methodologies, internal roles for this work and support from dedicated agencies to do it. This is not the case in general practice. While the same is not replicated in primary care, there have been forays.
The Australian Primary Care Collaboratives (APCC) operated from 2004 to 2014 and used a methodology developed by the Institute for Health Improvement to facilitate improvement in Australian general practice. To incentivise general practices to undertake data-driven improvement in patient outcomes and the delivery of best-practice care, the Practice Incentive Program Quality Improvement Incentive (PIPQI) was put in place.
Primary Health Networks (PHNs) were established to increase the efficiency and effectiveness of medical services and improve coordination of care. Some have been vanguards in innovation and transformation of the primary care system. Improvement knowledge and practice, however, remains variable across PHNs and general practice. PHNs have largely been left to self-determine the nature and intensity of their improvement activity rather than its scope being prescribed by government. As value-based health care and the ‘quintuple aim’ gain primacy, not only a culture of improvement but capability and capacity at both the PHN and clinical service delivery level becomes critically important[ix].
Other levers such as the Royal Australian College of General Practitioners (RACGP) Standards for General Practice and voluntary accreditation against these standards help assure quality and contribute to a culture of improvement.
All up, Australia has a patchwork of improvement initiatives. Some have shown promise but have not been sustained nor linked to an ongoing policy agenda. Others have helped elevate and encourage an improvement mindset but have lacked capacity and capability to see improvement practice fully embedded. None have been systemically and consistently implemented.
We need large-scale transformation across the whole GP sector and primary care in the longer-run, that takes us beyond the 20% of practices the APCC touched. This is our challenge, and our opportunity.
A national improvement strategy for primary care
Value-based, future-proofed primary health care commands enablers that will embed continuous improvement in mainstream general practices and overcome the numerous barriers to the adoption which range from lack of a system mindset and skills in change leadership and improvement.
Key enablers of participation in the APCC were beliefs and practice culture, the presence of a champion, opportunities for critical comparison and ‘meso’ level support from a primary care organisation such as a PHN. The identification of champions is consistent with other observations that organisations with successful records in improvement attribute their success to strong clinical leadership. Barriers to participation included insufficient time and resources, unfamiliarity with and inflexibility of the methodology, and inadequate meso-level support.
A systematic approach to improvement in Australian primary health care is needed if we are to strive towards excellence, innovation and transformation, acting on the principles Minister Butler has set for the future of Medicare.
A national strategy that is governed by guiding principles and specified actions at all levels within the system is the route we need to take.
Guiding principles
Principles for improvement originate in the manufacturing industries. While there are differences between these contexts and health care, these principles transcend sectors and apply to all modes of health care delivery:
Improvement takes a system view and advocates a culture of and commitment to quality throughout the organisation
Improvement efforts are human-centred and involve a commitment to co-production with consumers and communities. Striving to meet the needs of patients with safe, high-quality care is grounded in the idea of human beings caring for human beings encompassing patient, workforce, and community experiences [xvi]
Improvement recognises the need to create an organisational context that allows change to take place. This involves commitment to capability building; learning through education, training, and knowledge exchange; and implementation through collaboration and teamwork
Improvement is an iterative process that asks new questions, tests, and refines solutions before practical implementation at scale can occur
Improvement is rigorous. It involves extensive use of data analytics to identify areas for improvement; feedback systems to facilitate continuous improvement based on real-time insights; small pilots or ‘tests of change’ to implement innovations and refine them before wider rollout; and standardised approaches to reap the benefits of economies of scale.
Action at all levels
A strategic, cohesive approach to improvement involving interdependent steps at multiple levels is needed if we are to transform Australian primary health care.
Macro system
A clear vision from government authentically codesigned with clinicians, consumers and PHNs
A National Primary Care Transformation Centre to work closely with professional bodies, government, PHNs and hospital districts to:
Serve as a national dissemination hub for successful initiatives, spreading knowledge and learning, and supporting adoption
Build capacity and capability at all levels (C-suite, clinicians, consumers and managers and administrators in sectors that interface with primary care)
House a leadership ‘academy’ to support consumer and carer literacy and involvement, and champion joint leadership development between clinicians and consumers
Provide thought leadership to catalyse policy change
Leadership from professional bodies through standards and education
Support the creation and improvement of systems for transparent sharing of data about performance with patients and the public and local peers
Financial resources for PHNs to support improvement activity within their footprints
Funds to provide general practices and teams with the time and resources to engage in a whole-of-practice approach to improvement.
‘Meso’ system
Charge PHNs with the responsibility to coordinate regional improvement plans in collaboration with their local GPs, practices, and advisory structures. These would use resources from the Centre and involve:
Development of a shared vision and values for improvement
Leading a culture of improvement and innovation and investment in improvement through leadership and governance activities involving Boards, Clinical and Community Councils
Engaging placed-based Improvement Advisers to:
coordinate delivery of a suite of nationally developed and credentialled familiarisation, education, training and coaching programs for PHN and practice staff
support execution, monitoring, and evaluation of improvement initiatives in general practices
support the development of policies, programs, and networks for community engagement in efforts to improve quality of care, an essential ingredient to improvement.
Micro system
Clinical leadership development and support
Engagement with patients and carers
Support to develop knowledge and technical expertise in improvement methodologies for key practice staff, and associated competencies such as data literacy
Whole-of-practice education.
Conclusion: primary health care improvement is the future of health
Australians expect, deserve and value high quality, accessible and affordable primary health care services coordinated through a general practice team. General practice is under considerable strain and concern about its sustainability is reverberating in the community, in policy circles and in the media. This is a profound problem because high performing health care systems rely on strong, viable, vibrant GP-led primary care services. Supporting practices with systemic ways to improve, innovate and transform through proven improvement methodologies could never be more important.
This month the OECD, who says that healthcare has been a passive recipient of innovation, will host a High Level Policy Forum to examine the opportunities and challenges of incorporating transformative new tools into health system governance and improving clinical practice, and how can these developments improve the experience for patients and practitioners.
We have the opportunity to avoid a piecemeal approach and further develop improvement capacity and capability in primary care as a key system lever. An improvement ethos is fundamental to reshaping and revitalising Australian primary care, spearheaded by a revitalised general practice.
The Strengthening Medicare agenda should be the spur for a national improvement strategy for primary care. Such as strategy could be the anchor point for the leadership and cultural change theme of the Taskforce’s report.
Primary care improvement is the future of health and Australia has an opportunity to lead.
Acknowledgement
We wish to thank Angelene True and Dr Walid Jammal for their kind feedback.
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