The keynote address by John Hopkins University’s Prof Barbara Starfield at the recent ADGP conference in Perth, enlightened many on the value of primary care in a nation’s health. She also said specialty care has had too much influence over the health system for over 50 years, and because the evidence is that primary care is the prime factor in improving population health, specialists must now justify what they do in terms of how they contribute to primary care. “We know exactly what primary care is and how to measure it, public health knowledge is fairly good, but we cannot describe what specialty care does for primary health or what specialists are doing that relates to primary health care, let alone what they should be doing,” she said.
Prof Starfield has researched in detail, the role primary care plays in the health of more than 180 countries, from the USA and Australia to Venezuela and Botswana. Her key findings, in a nutshell, are:
- If you pour money (%GNP) and people into health, the key measurable effects of population health (such as five-year child survival rate) are likely to improve.
- However, considerable variation in outcomes within %GNP nation groups suggests that it is what health workers do that is important, more than how many you have on the job (see Figure 1). For example, why is there now a drop in life expectancy in high %GNP nations such as USA and Germany?
Good orientation to primary care is a more cost efficient way of achieving outcomes (less per capita health expenditure, for the same results – see Figure 2). Countries with a higher primary care focus have relatively better statistics on neonatal death, suicide, non-accidental death and potential life years lost. Those countries that do best are those with more equitable resource distribution, government-provided health services or health insurance, little or no private health insurance and no or low co-payments for health services. There is strong evidence from both industrialized and developing countries that reducing inequity in health care access improves national outcomes (see Figure 3).
Figure 2
Comparative figures within different countries show that for every extra primary care physician per 10,000 population, mortality rates will drop between 3-10%. Moreover, primary care physician supply is consistently associated with improved health outcomes (all-cause, cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, self-rated health), while the opposite is the case for higher specialist supply, which is associated with worse outcomes (see Figure 4, Table 1).
Countries with a poor ranking in primary care at a system level, also have this reflected in how health care is delivered in practices. That is, when the money and resources go to the wrong people, population health programs suffer.
Prof Starfield discussed why more specialists are (relatively) adverse to health, that is, provide less bang for your health buck.
She suggested specialist training in hospitals, where there is a higher prevalence of disorders, led them to embark on a cascade of tests in other situations, with poor yield. She said specialists deal poorly with co-morbidities. This is reflected in the practice guidelines produced for primary care doctors that are built on populations with no co-morbidities and therefore inappropriate to general practice.
Figure 4
The WHO defines Primary Care as: The provision of first contact, person-focused ongoing care over time that meets the health-related needs of people and coordinates care when people receive services at other levels of care; only those uncommon conditions outside the competencies of the primary care provider are referred.
Out of this WHO definition you can extrapolate the current catch-cries of WA’s health reformers, the four C’s – communication, coordination, collaboration, and chronic disease management. State Health is trying to import the principles of primary care into the tertiary public health system. Will it succeed?
During the conference panel discussion Health Dept Director General Dr Neale Fong pointed to pressures on our public health system. For example WA’s ED presentations increased 7% last year and 12% this year, despite in-house after hours primary care clinics and Health Direct phone triage. Yet despite these pressures he said hospital specialists were still doing 75% of their routine outpatient follow-ups when GPs were often better at this because they took greater account of co-morbidities.
A speaker from the conference floor suggested his push for primary care was top down, with a recent announcement of $4m towards a disease management primary care program but another $100m toward hospital medicine. In recent times, announcements of major State Health funding of specialist research in the public sector has some GPs further perplexed about priorities.
Yet in the context of the AGPAL forum Dr Fong said, “It is not the major hospitals in need of reform but the management of chronic disease. As far as the WA health system is concerned, primary and secondary prevention and self-management will underpin what we are trying to do. General practice and primary care are the linchpin because of their relationship with patients and the wider community.”
The barriers are fragmentation between State (hospital) and Commonwealth (community) services, with duplication and poor communication leading to wastage. There is a chronic health worker shortage in most health disciplines, and the anticipated 200 extra GP graduates will not be active in the community until 2013.
Dr Fong’s solution is to improve the distribution of functions between hospital specialists and primary care, and better coordinate management of chronic illnesses across both systems, mainly to prevent unnecessary (and expensive) hospital admissions. He said both systems will have to work with new types of health workers whose principal role is to coordinate the health care of at risk patient groups.
He said divisions of general practice were important to these reforms by providing better coverage to programs, ideas and better coordination. Meanwhile, he is working on building a better culture in the public health system with better leadership.
His final stage is to spend more on preventive care, currently 2.9% of health expenditure. More consumer involvement, including self care, was important.
DHA First Assistant Secretary Mr David Learmont is involved in administering the 300 programs and contracts totalling $600m with divisions, within the Commonwealth’s primary care budget of $3.6 billion. He said that divisions were critical to government in delivering on national priorities and it was their relationship with grass roots GPs that government valued most.
The management of chronic disease through DHA was focused on population-based programs, chronic disease recalls, patient support systems, and care coordination using a team approach that included practice nurses. The main challenge for divisions is to make it easier for government to tap into their potential, and earn their ?provider of choice’ role by delivering outcomes in a cost-effective way with equity.
But at the coalface in WA, at a time of health dollar prioritisation, many are arguing it is time that State Health overcame its turf war with the Commonwealth and gave priority to serious funding and resources for innovative primary care programs in WA.
Table 1: Health Care Expenditures and Mortality
5 Year Followup, United States, 1987-92
Adults (age 25 and older) with a primary care physician rather than a specialist as their personal physician
- had 33% lower cost of care
- were 19% less likely to die (after controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions)
Table 2: Primary Care and Infant Mortality Rates, Indonesia, 1996-2000
|
1996-1997 |
1997-1998 |
1998-1999 |
1999-2000 |
|
|
Primary care spending per capita* |
10.3 |
9.6 |
8.5 |
8.2 |
|
Hospital spending per capita* |
.1 |
4.4 |
4.6 |
5.3 |
|
Infant mortality |
20% improvement (all provinces) (1990-96) |
14% worsening (22 of 26 provinces) |