I am not sure if the readers of this blog have appreciated yet just what a fundamental change in our Primary Health Care delivery system is being proposed by the new Health Minister. While I have no strong feelings about the proposals I think it is vital they be carefully thought through.
In Australia, the UK, Canada and NZ at present primary care doctors have a very substantial ‘access control’ or gatekeeper function to the rest of the services provided by the health system (especially specialist care, investigations, non-urgent hospital care and allied health services especially). The objective of this approach is to try and ensure ant presenting clinical issue receives an appropriate clinical diagnosis and assessment before the patient is sent on for additional care. Overall the system seems to work pretty well although it is easy to identify occasions when medical involvement in accessing of care may be seen as un-necessary (e.g. physio for minor sports injuries and even –as is done overseas, the management of normal pregnancy).
However, with the gradual reduction in the number of GPs – especially outside the major metropolitan areas – clearly access to GP care for diagnosis and referral has become more difficult – and in some situations borders on the impossible.
What to do – to improve access and to reduce waiting to access care? Options include the use of more practice nurses, development of upgraded nurse practitioners, more use of midwives, train more GPs or dilution of the ‘gate-keeper’ function among others (e.g. super clinics etc).
In deciding what to do we need to be very sure we do not ‘throw the baby out with the bath water’. It is of note that, just as we are having this discussion we see in the USA there is an increasing view of the importance of that function.
June 26, 2008
The board of America’s Health Insurance Plans, the trade association for health insurers, has endorsed core principles for development of the “medical home” model, including liberal use of information technologies.
Under the medical home model, physician practices are redesigned to be more functional and workflow-friendly, and new processes are developed to focus on quality, safety and alternative reimbursement methods. The care model also calls for adoption of electronic health records, e-prescribing, clinical decision support, secure messaging and Web portal software to facilitate coordination of care among various providers.
Details of the principles can be found here:
The third paragraph makes it clear what is intended as ideal with an emphasis on holistic care delivery and a long term co-ordination of care role – supported by technology and allied health staff.
The associated press release makes the emphasis clear
“The patient-centered medical home would replace episodic care with a sustained relationship between patient and physician. This approach redesigns the care delivery model by assessing the level of illness or disease based on sound medical evidence; promoting coordination of care; and improving accountability for outcomes, patient experience, and utilization of services.
While there is current market experimentation going on to determine the appropriate structure for a medical home, the AHIP Board collaborated with other stakeholders to advance a model that focuses on the following:
- Practice redesign so care is delivered in response to a patient’s needs and preferences;
- Clear criteria for patient participation;
- Adoption of health information technology to facilitate evidence-based integrated care;
- Engaging and educating consumers and improving personal responsibility and behavior;
- Structuring payment to align with measurable improvements; and
- Pilot testing before moving forward with reformed payment models or practice redesign.”
Now the AHIP is not some fringe group – their tag line is “Providing Health Benefits for Over 200 Million Americans.”!
With the US having been the archetypal example of a ‘gatekeeper-less’ health system one is forced to wonder if they know something the Minister has not yet caught up with?
I am not sure what the right answer is in all this but I am sure I don’t want a system that is working quite well changed without very careful consideration of all the options – including the use of more Health IT – and I certainly don’t want change triggered because of the current stridency of the AMA. That would be very sad!
If we change all these roles and responsibilities we need to be sure it will be for the better.