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PULLING together Australia’s “Byzantine-like system of federated states”, placing more value on the capabilities and experience of GPs, and sharing data and experiences could be the most important lessons learned from our COVID-19 pandemic response, say experts.
In the early years of the COVID-19 pandemic, Australia’s acute care and public health response was hailed as world leading. However, the authors of a Perspective published in the MJA say the pandemic has highlighted many fragilities in the Australian health system that need urgent improvement.
Fragmentation between hospital and primary care, including “Byzantine-like system of federated states”, leads to fragmentation and poor coordination of care. In addition, “geographical barriers, workforce shortages and issues relating to acceptability of services limit health care access for residents of rural, regional and remote communities, Aboriginal peoples and Torres Strait Islanders, and together with an inadequate focus on prevention, limit progress towards health equity”, wrote the authors, led by Professor Sarah Larkins, Professor of Health Systems Strengthening at James Cook University.
Lack of primary care in pre-pandemic planning
The issues began with the pre-pandemic planning, with Larkins and colleagues highlighting a lack of primary care involvement.
“Early central planning and discussion rarely involved primary care providers — from private, public or Aboriginal community controlled health sectors — and highlighted a lack of regional health care planning structures. In fact, early messaging for GPs reflected how to avoid contracting SARS-CoV-2, rather than how best to care for patients who contracted the virus,” they wrote.
Chair of the Victorian faculty of the Royal Australian College of General Practitioners Dr Anita Muñoz told InSight+ that a devaluing of the GP specialty has meant many have found it hard to define what GPs are capable of, leading to a dismissal of GP involvement in pandemic planning.
“[There is an assumption] that GPs have fundamental limitations, which is totally incorrect,” she said.
“As a result of that, there have not been adequate conversations with GPs about their role in public health measures, which has left a gaping hole in in the systems that have been designed and implemented.”
This lack of GP involvement in planning impacted care throughout the COVID-19 pandemic.
“As the pandemic evolved, this fragmentation and lack of planning involving the primary care sector, together with policies that ignored the economic realities of running general practices, limited the provision of integrated patient-centred care for people with COVID-19 in the community,” Larkins and colleagues explained.
Calls for an integrated funding model
According to Dr Muñoz, there was another reason primary care wasn’t involved in pre-pandemic planning.
“Often a lot of these responses were led by state jurisdictions and states have had a very hands-off approach to the specialty of general practice because of the strictness of the funding paradigm,” Dr Muñoz continued.
This resulted in a siloed approach to pandemic management.
“Primary Health Networks (PHNs) were tasked with coordinating supply chains and care networks, but in many cases they lacked the required clinical and organisational networks, and they were not provided with coordination from federal and state governments that would enable them to progress with this effectively,” Larkins and colleagues wrote.
Dr Muñoz called for all sectors to work together and to recognise that the Australian health system is a single entity.
“We need care to follow the patient’s journey, not to be determined by different geographical and political locations in which care can be delivered.
“We need the health care systems to be willing to work together in the interests of patient outcomes, not asking patients to mould themselves to fit archaic funding models,” she explained.
Sharing the wins and the losses
Larkins and colleagues highlighted one group that formed a partnership to successfully reduce fragmentation of care. In Melbourne, COVID Positive Pathway partners included cohealth, North Western Melbourne Primary Health Care Network, Melbourne Health, Western Health, Werribee Mercy Hospital and GPs across the region, with support from the Victorian Government Department of Health.
They provided a coordinated approach to COVID-19 care, which included triage and assessment from a community health organisation (cohealth), hospital partners for higher risk and more acute care, and local GPs providing regular care every second day for the lower acuity group (80% of patients).
But in most parts of the country, GPs were largely left to their own devices.
“One of the problems is that each health network was doing something different or slightly different – in some instances, heavily defending their catchment areas, which lead to a lot of difficulty for GPs and patients who live and work across multiple catchments,” Dr Muñoz said.
There needs to be more sharing of positive and negative outcomes in order to improve primary care, she said.
“In health, and particularly in research, there can be a jealous guarding of data and outcomes, which we need to dispense with. Unless we share our data and share our learning and encourage other people to use what we’ve done and make it fit their context, then we are stymieing our own efforts to improve the health system overall,” Dr Muñoz explained.
Redesigning the models of care will improve outcomes
Beyond COVID-19, Larkins and colleagues highlighted an urgent need for redesigned models of care in the health system overall.
“The first of these priorities is co-designed regional models of care involving primary care providers and referral hospitals working together with PHNs, [Local Hospital Networks], peak bodies and clinician leaders to implement referral, care and escalation pathways,” the authors wrote.
Dr Muñoz agreed.
“If we can get different funders to fund and reward GPs for spending good quality time to address complex comorbidities in the context of social issues, then the outcomes will improve,” she said.
“Overall, caregiving will be more cost effective. But we need, for example, to get patients discharged from hospital faster, and pay GPs to spend prolonged consultations with those patients to make their care in the community a success.”
Ultimately, this comes down to GP funding.
“Unless we have a serious investment in general practice very soon, our health system will collapse. Spending between 7% and 8% of the health budget on general practice is absolutely inappropriate and unsustainable.
“In countries in which they have invested heavily in general practice, their health system has produced a better outcome for fewer taxpayer dollars. And we need to emulate that,” Dr Muñoz concluded.
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All GPs have a complex load with the increased subspecialisation , , reduction in OPD services and reduction in community health with massive increase in mental illness and ageing population with less family support for older people due to workplace demands and high cost of living of adult children.