In addition to modernising existing services as described in section 2, there is the potential to introduce additional funding to encourage high-quality care as described in the RACGP Vision. These payments can be made to practices and GPs who are providing continuous, comprehensive, coordinated and team-based care.
In order to encourage flexibility of care by practices, including care provided appropriately in non–face-to-face settings and by multiple members of the practice team, payment for additional services could be provided through the existing Practice Incentives Program (PIP). Care could also be provided through an enhanced Service Incentive Payment (SIP) to GPs. Alternatively, a modernised MBS could provide additional fee-for-service payments for non–face-to-face care, or for care delivered by the broader practice team.
Continuity of care: Formalising the relationships between patients and their GP by introducing voluntary patient enrolment
Over 80% of Australians have a usual GP and 90% a usual practice.3 However, in the current system there are high levels of fragmentation, with no formal system for practice enrolment and patients frequently attending multiple general practices.2
The Australian Government and state and territory governments have a role in supporting:
- the provision of continuing care rather than episodic treatment of illness
- preventive healthcare
- monitoring of health outcomes
- better coordinated care within practices as well as across the broader healthcare system.
Continuity of care can be facilitated by formalising the relationship between patients and their GP and practice through voluntary patient enrolment (VPE). Under a voluntary system, patients will be able to choose whether to enrol with a practice, and GPs and practices will choose whether they wish to offer enrolment.
VPE will bring benefits for patients, providers and funders
It is important that all patients have the opportunity to enrol with a preferred practice. An ongoing relationship with a regular GP is highly valued by all patients. The Australian Government’s Health Care Homes trial involved VPE for patients with chronic and complex conditions. However, limiting VPE to patients with chronic disease will reduce the opportunity for other patients to benefit and will restrict wider improvements to the healthcare system.
VPE will facilitate practices to better understand the population that they are caring for, allowing for effective planning and use of resources.
Implementing VPE
VPE is a mechanism to enable continuity of care and direct additional funding outside of fee-for-service to support the provision of high-quality, comprehensive and coordinated care.
Enrolled patients will be expected to receive the majority of their care from their enrolled practice with their preferred GP. Enrolled patients should continue to be able to access all payments, including rebates via fee-for-service as currently administered through the MBS. Differential rebates for care provided at enrolled practices, versus non-enrolled practices, could also be introduced into the MBS. This would provide further incentive for patients to access the majority of their care from their regular GP or practice.
In practical terms, GPs should be supported to engage in meaningful discussion with patients to describe the benefits of enrolment and establish mutual obligations. Mechanisms must be put in place to minimise any risk of gaming, whereby patients are enrolled superficially to enable a practice to bill an enrolment fee. At the same time, this structure will support the additional time required to enrol a patient.
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Health service coordination: Improving coordination between community and hospitals
As well as providing high-quality general practice care, GPs also have a significant role in supporting their patients as they encounter the broader health system. This stewardship role involves helping patients gain timely access to the health and social services they need, as well as ensuring that limited health resources are not wasted on duplication or fragmented care.
Additional funding is needed for GPs to manage patient transitions between their general practice care and the rest of the health system. This involves supporting care coordination and integration activities. This funding will also encourage improved handover when patients return from hospital if there is timely and meaningful communication between general practices and other service providers, including hospitals.
As part of their role in coordinating care for patients, GPs have a significant stewardship role in guiding patients through the complex health system. The stewardship role of GPs not only provides an essential support to patients, but also brings significant savings by providing clinically appropriate referrals to other health providers. GPs’ stewardship role also reduces duplication and unnecessary care.
The savings generated from better coordination should be reinvested to support GPs and practices to coordinate care.
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General practice infrastructure: Ensuring that practices have the tools required to provide comprehensive care
The indirect costs of running a practice, such as the costs associated with improving the infrastructure required to provide quality care, are not supported by the current funding structure.
Practices should be provided with funding to support physical and IT infrastructure, enabling the adoption of new technologies and increases to practice capacity, as well as:
- maintenance and improvements to physical infrastructure
- maintenance or introduction of new IT hardware/software
- the training required to ensure quality use of technology.
Enabling the adoption of these activities or supports would assist in:
- ensuring that practices have the appropriate space to provide safe and high-quality comprehensive care
- improving the management of patient information
- reducing administrative burdens
- improving service integration
- facilitating a more comprehensive range of services to be provided
- encouraging the delivery of non–face-to-face care
- recognising patient complexity and responding to health inequalities with a complexity loading payment.
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Recognising patient complexity: Responding to health inequalities with a complexity loading payment
Based on the enrolled practice population, a complexity loading payment to GPs and practices could be calculated according, but not limited, to:
- socioeconomic status of the community in which the practice operates
- rurality of the practice
- medical workforce shortage (based on state/territory/national programs)
- areas of social dislocation and poor public transport
- number of patients who identify as an Aboriginal and/or Torres Strait Islander person
- age of individual patients.
People in rural and remote Australia experience worse health outcomes, with high levels of complex conditions and chronic disease, as well as higher rates of potentially preventable hospitalisations.4
The GP-to-patient ratio decreases as remoteness increases, meaning that there are fewer GPs per person in regional and remote settings.5 Addressing Australia’s general practice workforce maldistribution issue will help to address these health inequities.
GP shortages in rural areas has been an ongoing issue in Australia that successive governments have yet to solve. Common responses by state/territory governments and the Australian Government, such as training more doctors, or providing monetary incentives for them to work in rural or remote locations, have failed to adequately address these issues.6
An innovative and multifaceted solution must be implemented to address the maldistribution of GPs in rural and remote areas. In order to be successful, any approach taken must identify and address the root cause of maldistribution in these settings.
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General practice research: Ensuring a high-quality and evidence-based primary healthcare system
Inadequate evidence relevant to general practice hinders GPs’ efforts to provide evidence-based care, as guidelines developed from research in other settings may not be appropriate for their patients.7,8
As the cornerstone of primary healthcare delivery, general practice research requires additional funding mechanisms that support:
- the maintenance of existing practice-based research networks
- a national program for research training in general practice
- a general practice research Fellowship program, offering eight 4–5-year Fellowships to develop GP research leaders
- National Health and Medical Research Council (NHMRC) grants for research projects specific to general practice (ie projects with direct relevance to general practice and that involve one or more GPs as chief investigators)
- an NHMRC centre for research excellence in general practice/primary care.
Practices should also be supported to participate in general practice research through an appropriate practice payment.
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Comprehensive care: Supporting patients to access the range of services they require
Targeted payments support general practices to continue to offer a wide range of additional services, beyond those considered standard general practice services.
Additional services may include:
- planned preventive healthcare
- aged care in the community
- residential aged care
- palliative care
- facilitating or providing after-hours services
- home visits (where appropriate)
- minor procedures
- mental health services
- Aboriginal and Torres Strait Islander health services
- services that are appropriate to other population groups, including refugees and culturally and linguistically diverse patients.
To be eligible for payments, practices could demonstrate the comprehensiveness of the services that they provide. Provisions could also be put in place for a percentage of the payment to be apportioned to the GPs directly providing the services.
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Enhancing team-based approaches to care
A team-based care payment for practices would support the employment of the entire general practice team, including nurses, Aboriginal and Torres Strait Islander health practitioners/workers, allied health professionals and non-dispensing pharmacists.
It would be vital for such a payment to be made available to all practices, regardless of their location, in order to support equity of access for patients.
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