General practice in the era of funding reform

How we fund our health system to achieve the most effective, efficient and equitable outcomes is high on the political agenda. Australia has just experienced a federal election dubbed “the health election” for one of the largest funding boosts to Medicare promised by both major parties.¹ This issue of the MJA is dedicated to general practice — the bedrock of the health system that has arguably been in crisis for several years.

A centrepiece of Labor's campaign on health was a pledge to build more bulk-billing urgent care centres around the country. These centres aim to bridge the gap for urgent illnesses when patients cannot see their general practitioner and reduce pressure on emergency departments (EDs).²

In this issue of the MJA, Savira and colleagues³ conducted a scoping review to examine the effectiveness of urgent care centres. They examined studies conducted in clinics in the UK, Europe and the United States and found that the results with respect to reduction in ED visits were mixed. While some studies reported that the introduction of these clinics was associated with a reduction in ED visits, others often showed no changes or an increase in presentation to ED minor injury units. Importantly, most studies examined showed a reduction in hospital admission rates in places where urgent care clinics had been set up. Although most patients in consumer surveys examined were happy with the service, continuity of care was a concern expressed by both patients and practitioners. Even though the review was limited by the high heterogeneity of methodologies examined, it provides a warning about relying on a model without adequate governance and formal assessment of cost effectiveness. Indeed, a recent interim report by the Department of Health and Aged Care found that although the cost of seeing a doctor in an urgent care clinic is lower than in an emergency department, this cost is at least five times that of seeing a general practitioner for a standard consult.⁴

Continuity of care has been an ongoing issue in primary health care for several years. Unlike the UK and New Zealand, where patients are often enrolled into their local primary care clinics for care, in Australia most people can visit any general practitioner anywhere for care, which often leads to a significant amount of fragmentation of care and over ordering of investigations.⁵ The MyMedicare initiative that has been recently rolled out in Australia attempts to correct this.

Bates and colleagues⁶ in their scoping review for this issue examined enrolment models in other countries to elucidate their impacts on continuity of care. They found little evidence that enrolment improved continuity of care; however, study populations had high levels of pre-existing patient engagement with a usual general practitioner The review provided evidence that enrolment can be used to support other primary care reforms such as preventive care and management of chronic conditions, and demonstrated how other reforms, such as incentives or increased access to services, can affect uptake of enrolment.

For MyMedicare to work, practices and patients need to see value in enrolment. This value proposition will be hard to make without more targeted research evaluating, and then demonstrating, the benefits of enrolment, not just for individuals who have a usual general practitioner, but for those who do not. Although the review noted that the MyMedicare scheme currently has limited incentives for patients, there have been proposals to tie in funding for chronic care plans and allied health visits to a patient's nominated general practitioner and practice on MyMedicare.⁷ This will likely pressure general clinics to enrol patients specifically to their clinics.

The overarching problem most general practitioners have with investment in primary care is that often the governments do not seem to want to consult with them with regards to their experiences and opinions on how unprecedented levels of Medicare funding might best suit their patients. Most clinics currently run on the slimmest of margins and the bulk-billing incentive still does not meet the gap that mixed billing currently provides most clinics.⁸ Without effective primary care most Australians will be left without adequate health care. A substantial proportion of research needs to be carried out on effective models of care focusing on general practitioners with general practitioners as a core part of the research and assessment team.