DRAFT

Working with PHNs to improve the health of Queenslanders

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Introduction RACGP Queensland is keen to engage and work with Queensland based Primary Health Networks (PHNs). As outlined in the RACGP position statement on Primary Health Networks, the RACGP believes there is an opportunity for PHNs to add value to the community, through relationship building and supporting the provision of quality general practice services, including care coordination and integration (1). We believe that a key role of PHNs will be to assist and support GPs and other primary healthcare providers to deliver services. PHNs are ideally situated to facilitate improved integration between primary healthcare providers and other healthcare sectors, including hospitals, aged care, mental health care and palliative care. Increasing meaningful communication between these groups, to improve collaborative care through innovative models, should be a key goal. The RACGP is encouraging GPs to take on leadership roles on PHN strategic/clinical councils and committees. In addition we have identified concrete targets that should be aimed for in primary healthcare reform at a local level. The targets are presented in this paper and we envisage that PHNs could play an important role in achieving the goals, in collaboration with RACGP Queensland as appropriate. We look forward to working with PHNs to improve the health of Queenslanders. On behalf of the RACGP Queensland Board, Dr Edwin Kruys

Background The Royal Australian College of General Practitioners (RACGP) is the peak professional body for general practice in Australia. We represent more than 30,000 members working in or towards a career in general practice. RACGP Queensland has 5100 members working in a variety of primary healthcare, hospital, rural and urban settings. The scope of clinical general practice is challenging, spanning prevention, health promotion, early intervention and the management of acute, chronic and complex conditions. Services are provided in a range of settings, including the practice, home, residential aged care facility, health service, outreach clinic, hospital, and community (2). General practitioners (GPs) understand the socio-economic and environmental determinants of health and the contribution made by other health professionals, sectors and community groups. The relationship between a patient and their family GP is the core of quality primary healthcare. In their role, GPs aim to:

work closely and respectfully with other health professionals and services to deliver

accessible, efficient, and integrated care of real people

lead, support and coordinate their clinical teams,

contribute as required to external clinical teams, engaging with diverse specialists and other

sector services according to individual patient or family needs.

General practice is the first point of contact for the healthcare system, with nearly 85% of Australians seeing a GP each year. At the same time general practice is proven cost-effective: spending on general practice represents less than 8% of the overall government healthcare budget.

General practice services in Australia cost taxpayers only $334 per person

a year. This highlights that general practice is fantastic value (4).

The RACGP recently published its Vision for general practice and a sustainable healthcare system (the Vision) (5). The Vision is based the RACGP’s definition of quality general practice, and is informed by the patient-centered medical home model. Developed in consideration of the broader healthcare system, we envisage the Vision will be a catalyst for change. In it, we propose a major reorientation of the current system to better support the delivery of quality, sustainable and effective patient healthcare, designed to meet the needs of our patients and their communities. At a state level, meaningful engagement with PHNs, government, health departments, and patients is a key part of achieving meaningful reform of the health system, including implementation of the patient-centered medical home. The RACGP is committed to evidence based, equitable quality care, innovation and a collaborative approach. In this document we have outlined the following concrete targets that should be aimed for in primary healthcare reform at a local level:

1. Working together

2. Improving continuity of care

3. Driving better data exchange and communication

4. Developing new models of care

We are ready to collaborate with PHNs to achieve these targets.

1. Working together Long-term relationships positively influence knowledge exchange, understanding and trust. The opportunity to talk to colleagues about a clinical problem is mutually beneficial and in the best interest of our patients. Face-to-face interactions and telephone or video consultations are sometimes underutilised, even though they are preferred over using email which has the potential to include unclear meanings or unnecessary emotional content. Where possible health providers should be given the opportunity to discuss patient needs and cases with each other. This is especially important for GPs working in rural and remote areas. This principle is, of course, not only applicable to healthcare. As the Australian Institute of Company Directors states:

“Improve decision making by building the ‘social muscle’ of the decision-making team, breakfasts, lunches, dinners, conference attendance, site visits etc.” (7)

Avoiding bureaucracy We should be careful that non-clinicians do not create barriers to effective inter-collegial communication. For example, referral letters and discharge notifications should contain the necessary information to allow the next healthcare provider to do their job properly. However, it is important to avoid more bureaucracy regarding referral requirements and provide mechanisms to override any referral rules implemented. Decisions by individual healthcare organisations often affect others. Care should be taken that a unilateral decision made in one part of the healthcare system does not negatively impact other parts. Nicholson et al found in a study published in the Medical Journal of Australia (MJA) that a range of specific governance elements are important to support integrated care across the primary–secondary care continuum, including (8):

Joint planning: Governance arrangements included formal agreements such as memoranda of

understanding, joint board memberships and multilevel partnerships in the planning process.

Shared clinical priorities: The use of multidisciplinary clinician networks, a team-based

approach and pathways across the continuum to optimise care.

Professional development supporting joint working: This allows alignment of differing cultures

and agreement on clinical guidelines.

Recommendation:

PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.

2. Improving continuity of care Integration of care is more important than ever. However, new initiatives and models of care should be carefully evaluated to ensure they don’t fragment care and undermine proven models of healthcare delivery, including the GP/patient relationship. Fragmentation of care negatively impacts on patients’ health – even when provided with the best of intentions.

New initiatives and models should be carefully evaluated to ensure they

don’t fragment care and undermine proven models of healthcare delivery

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

The World Health Organisation (WHO) cautions that integrating health services is a means to an end, not an end in itself (9). Better integration may provide cost savings but it is not a cure for inadequate funding or resources. The WHO also reminds us that there can be a difference between integration from a consumer point of view, which may mean seamless access to services, and professional integration, which is usually achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand. When we’re talking about better integration, it is useful be clear on what problem we want to solve:

Are we trying to improve the patient journey through the health system?

Do we want to support health professionals to deliver better care?

Or is it about finding ‘efficiencies’ in the healthcare system and reducing costs?

The benefits of continuity of care Continuity of care is a crucial element of general practice, with numerous proven long-term benefits (10,11). Unfortunately, it seems this principle is sometimes sacrificed in new initiatives and models for the sake of short-term results, convenience or commercial interests.

Continuity of care is sometimes sacrificed in new initiatives and models

for the sake of short-term results, convenience or commercial interests.

Continuity is often described as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. Unfortunately, other terms are used synonymously, such as ‘care coordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’. Haggarty et al argue in the British Medical Journal (BMJ) that continuity is not an attribute of practitioners or organisations (11). They define continuity as the way in which individual patients experience integration of services and coordination. The authors state that “In family medicine, continuity is different from coordination of care, although better coordination follows from continuity. By contrast, a trade-off is required between accessibility of healthcare providers and continuity.” It is important to distinguish the three types of continuity of care, as explained by Haggerty et al:

Informational continuity: The use of information on past events and personal circumstances to

make current care appropriate for each individual

Management continuity: A consistent and coherent approach to the management of a health

condition that is responsive to a patient’s changing needs

Relational continuity: An ongoing therapeutic relationship between a patient and one or more

providers.

Continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an eHealth database. Understanding of individual patients’ preferences, values, background and circumstances cannot always be captured in health records. Health providers who have a longstanding relationship with their patients usually know this information. Case 1 demonstrates the importance of continuity of care in general practice and some of its benefits, such as health monitoring and opportunistic screening.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

Of course, continuity of care exceeds disciplinary and organisational boundaries. The RACGP defines continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers.” (10) There is ample evidence that continuity of care results in improved patient health outcomes and satisfaction. Relational continuity reduces both elective and emergency admissions. Evidence also indicates that primary care is associated with a more equitable distribution of health. (10,11, 17, 18, 19, 20, 21)

Figure 1. The key elements of the healthcare home. Source: RACGP Vision (5)

Case 1: “Vaccinations: not just about giving a needle” Community pharmacies play an important part in patient care, which includes the management of medication therapy in collaboration with GPs, and the provision of triage services for a range of community health concerns. However, while the RACGP recognises the benefits of involving community pharmacy as part of a GP-led multidisciplinary team, there are significant health concerns regarding the proposed expanding role of the Pharmacists Vaccination Program in Queensland (12), which are not offset by the perceived convenience for patient access to immunisations in a pharmacy setting. A visit to the patient’s usual general practice, even if ostensibly for a flu vaccination, provides an opportunity for advice and enquiry regarding health promotion activities and other aspects of the patient’s health. This includes delivering a wide range of preventive and/or screening activities during a standard consultation (13). Patients who are vaccinated at a pharmacy miss these opportunities for important health interventions because pharmacists are not trained to diagnose or manage care, creating missed screening opportunities and potentially future adverse health events for patients. In addition to this RACGP Queensland has other concerns related to the separation of commercial interests and dispensing roles. There is a real risk that recommendations for treatment and prescribing are not evidence-based and influenced by financial and commercial factors. Increasing vaccination rates among adults in Queensland is important. However, the impact of patients presenting to pharmacies instead of general practice will result in fragmentation of care, missed opportunities for screening and preventative health, and possibly reduced patient safety, increased risk, and more health waste.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

Avoiding unnecessary hospital presentations Keeping people out of hospital has always been a task of GPs. The Australian Institute of Health and Welfare (AIHW) defines potentially avoidable hospital presentations as “admissions to hospital that could have potentially been prevented through the provision of appropriate non-hospital health services”. Various research groups found that poor access to primary care is strongly related to more potentially avoidable hospital admissions (17). Increasing comprehensiveness of care by GPs, especially as measured by claim measures, is associated with lower Medicare costs and fewer hospitalisations (18) and, not surprisingly, the rate of hospital admissions drops when people have their own GP (19). There are a growing number of patients with complex health needs who experience unnecessarily poor health outcomes. Inadequate linkages between general practice, state or territory-funded services, other medical specialists and health professionals fragments care, and may lead to unnecessary hospital admissions or emergency department presentations.

When adequately supported, GPs play an important role in keeping people

out of hospital

When adequately supported, GPs play an important role in keeping people out of hospital. It is important however that hospital avoidance projects help to build capacity and facilitate access in primary care and respect the principle of continuity of care. Case 2 illustrates that not all hospital avoidance initiatives have the intended effect and, despite best intentions, fragment care.

Case 2: “Hospital avoidance project creates further fragmentation” RACGP Queensland has identified several potential and unintended consequences of the “Spot On” Queensland Health hospital avoidance trial that may create further fragmentation of care for patients. In this project QAS will bring selected patients to a GP practice instead of the hospital; if the usual GP (not funded) cannot accept the patient, other ‘Tier 2’ GP practices, funded by Queensland Health, have to accept the patient. While the positive intent of the program is to have category 4/5 patients appropriately treated in a general practice setting, rather than hospital emergency department, RACGP Queensland is concerned that the reality of time and resourcing constraints may result in:

the by-passing of first contact with the usual GP, given that the project provides QAS

with certainty that a Tier 2 practice will be required to accept the patient.

the inadvertent incentivising for patients to access the project as an alternative to

seeing their own GP – e.g. the provision of free transport to a bulkbilling practice where

patients will likely have a shorter waiting time to see a doctor than at the hospital or at

their usual general practice.

undermining of stable and enduring relationships between a GP and patient, shown to

have a positive impact on patient health outcomes, including hospital avoidance.

The RACGP believes funding for innovative primary care projects should encourage continuity of care by the usual GP or GP practice by improving access and capacity. If patients do not have a usual GP they should be encouraged to visit and build a relationship with a GP of their choice as this results in superior care and less costs for the community.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

The patient centred medical home, voluntary patient enrolment and direct, efficient (electronic) communication between providers are important ingredients to ensure improved care for people with chronic and complex health conditions and better integration of health services. Recommendation: PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.

3. Driving better information exchange and communication Because of their central role in the healthcare system, GPs are the custodian of, and conduit for, key patient clinical information (2). Direct, secure, electronic communication between GPs, specialists and allied health providers is beneficial for optimal patient care, clinical prioritisation, and for facilitating important and timely feedback to referring practitioners. This could occur via encrypted email, video conferencing and/or a secure messaging system, preferably integrated in existing clinical practice software. Communication between primary healthcare providers Due to Australia’s transient population, secure and reliable electronic information exchange between healthcare providers is imperative. However, the My Health Record (formerly PCEHR) remains an underutilised option given many technical and medico-legal related issues (15). Fortunately, there are other e-health solutions available for consideration. For example, in New Zealand and the UK they have found a way to transfer GP health records electronically if a patient changes their GP - called ‘GP2GP’ (16). This is a low-cost software application that securely transfers an electronic health record from one GP practice to another, and automatically stores information in the relevant sections of a patient’s record. The same technology could also be used to connect allied health professionals, community pharmacies, and specialists.

Hospital discharge information Timely and quality discharge information is vital. Delayed correspondence from hospitals to referring medical practitioners remains one of the biggest problems for GPs who are frequently dealing with returning patients without any information from the hospital. Recent legal cases have again identified the potential danger to patients from delayed transfer of clinical information.

Delayed correspondence from hospitals to referring medical practitioners

remains one of the biggest problems for referring practitioners

Easy online electronic access to hospital patient information, like pathology and imaging, will assist GPs to provide follow up care after patients have been discharged from hospital and help reduce duplication of services and tests. However, access to this information must not carry additional medico-legal responsibility on the part of the GP. GPs must receive (electronic or hard copy) discharge summaries and other correspondence to include in their patient records stored within practice software.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

All necessary information should be supplied in this correspondence and it should not be left to the GP or practice staff to chase up information from the hospital. GPs need to ensure that their referrals are of sufficient quality and consistent with RACGP standards, so that they are useful for practitioners who deliver patient care in different health settings. The use of a universal template would improve communication between providers. Referral letters may contain additional, locally agreed, information, but not extensive extra information (such as patient questionnaires). These are the responsibility of the requesting organisations, and GPs should not be made responsible for the collection and supply of this information.

Secondary use of data Under well-defined circumstances, it is reasonable to share health information with other parties, including PHNs for the purpose of health surveillance, quality improvement and/or research. In these cases the purpose must be clear and all parties, including patients, should be fully aware of what happens with their personal health information and provide consent. However, this cannot be mandated/forced in general practice either directly or indirectly. Recommendation: PHNs need to play an important role in facilitating better information exchange between healthcare providers.

4. Developing new models of care Evidence from Australia and other countries shows that substantial savings can be achieved through greater investment in general practices and their multidisciplinary teams (5). New innovative models of care should therefore be explored. Potential models for exploration could include:

beacon practices

special interest/accredited practice and GPs

sourcing direct access to certain hospital wait lists for procedures (e.g. endoscopies)

hospital consultants becoming more available to give advice and/or training to GPs and their

patients in the community

non-dispensing pharmacists working in general practice.

Substantial savings can be achieved through greater investment in general

practices and their multidisciplinary healthcare teams

These models could potentially:

improve the quality of patient care

reduce public hospital waitlists and slow down the growth of the waitlist

be sustainable and cost-effective

encourage integration of care between primary, secondary and tertiary care

improve the patient experience

improve equity of access.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

Innovation and new models of care should not be confused with task substitution. There are many factors why it would be good to first look at what is already working & successful in Queensland and what is not. All models should be evaluated carefully to ensure that they don’t negatively impact on general practice and its core values such as continuity and quality of care. Integrated care is challenging due to various characteristics of the Australian health care system (17). In addition, well-intended reform can have adverse effects on the delivery of quality patient services. Case 2 is an illustration of an innovative model that is not preferred by the RACGP because it increases fragmentation of patient care. The Brisbane beacon model is an example of a multidisciplinary, community-based, integrated primary-secondary care health service. This model has shown that it can reduce hospitalisations and curtail increasing demand on finite health services for people with complex diabetes (19). The model, delivered by GPs with advanced skills, produced clinical and process benefits compared with a tertiary hospital diabetes outpatient clinic (20). Early results from other research in Queensland also indicates that integrated clinical care models have benefits, including a reduction in hospital services (21). Overall, there are significant benefits from supporting and adequately resourcing general practice and its interactions with other parts of the health system. To quote the National Health and Hospitals Reform Commission (22): “We believe that strengthened primary health care services in the community, building on the vital role of general practice, should be the ‘first contact’ for providing care for most health needs of Australian people.”

Recommendation: PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

Resources

1. RACGP position statement on Primary Health Networks http://www.racgp.org.au/download/Documents/Policies/Health%20systems/RACGP-Position-statement-Primary-Health-Networks.pdf

2. What is General Practice? http://www.racgp.org.au/becomingagp/what-is-a-gp/what-is-

general-practice

3. General practice activity in Australia 2014-15: Family Medicine Research Centre. The University of Sydney http://ses.library.usyd.edu.au/bitstream/2123/13765/4/9781743324530_ONLINE.pdf

4. Annual Medicare Statistics. The Department of Health http://www.health.gov.au/internet/main/publishing.nsf/Content/Annual-Medicare-Statistics

5. RACGP’s Vision for general practice and a sustainable healthcare system

http://www.racgp.org.au/support/advocacy/vision/

6. Seven Characteristics of Successful Work Relationships http://www.aafp.org/fpm/2006/0100/p47.html

7. AICD Course, Chapter 2 ‘Decision making’.

8. Best-practice integrated health care governance - applying evidence to Australia’s health

reform agenda. Is Australia ready for evidence into policy? https://www.mja.com.au/system/files/issues/201_03/nic00310.pdf

9. Integrated health services - What and Why?

http://www.who.int/healthsystems/technical_brief_final.pdf

10. Continuity of comprehensive care and the therapeutic relationship http://www.racgp.org.au/your-practice/standards/standards4thedition/practice-services/1-5/continuity-of-comprehensive-care-and-the-therapeutic-relationship/

11. Continuity of care: a multidisciplinary review

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC274066/

12. Pharmacy immunisation trial broadened http://statements.qld.gov.au/Statement/2014/7/9/pharmacy-immunisation-trial-broadened

13. Preventive activities in general practice 8th edition. RACGP. http://www.racgp.org.au/your-

practice/guidelines/redbook/

14. Characteristics of general practices associated with numbers of elective admissions http://jpubhealth.oxfordjournals.org/content/early/2012/03/23/pubmed.fds024.full.pdf

15. RACGP urges Government to re-think suggested ePIP model

http://www.racgp.org.au/yourracgp/news/media-releases/racgp-urges-government-to-re-think-suggested-epip-model/

16. GP2GP http://www.patientsfirst.org.nz/services-products/gp2gp

17. Potentially avoidable hospitalisations in Australia:

Causes for hospitalisations and primary health care interventions http://www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/publications/pdfs/phcris_pub_8388.pdf

Working with PHNs to improve the health of Queenslanders - RACGP Queensland

18. More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations http://www.ncbi.nlm.nih.gov/pubmed/25964397

19. Impact of an integrated model of care on potentially preventable hospitalizations for people

with Type 2 diabetes mellitus http://www.ncbi.nlm.nih.gov/pubmed/25615800

20. Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial http://www.ncbi.nlm.nih.gov/pubmed/23758279

21. Case conferences between general practitioners and specialist teams to plan end of life care

of people with end stage heart failure and lung disease: an exploratory pilot study http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020309

22. A healthier future for all Australians: an overview of the final report of the National Health and

Hospitals Reform Commission https://www.mja.com.au/journal/2009/191/7/healthier-future-all-australians-overview-final-report-national-health-and