Primary Care Partnerships: New Directions in Victorian Primary Health Care

Primary Care Partnerships: New Directions in Victorian Primary Health Care Merrian Oliver-Weymouth The changes to the system of primary health care in Victoria introduced by the former Victorian Liberal government, reflected a particular political philosophy of government, not just a view about health care. These changes, although substantially modified by the subsequent Labor Government nevertheless are still evident in the current model. This article will describe the current models for primary health care and some of the issues and concerns around primary health care from a consumer perspective. In some ways, the changes to public services in Victoria have been more far reaching than elsewhere in Australia closely paralleling the public sector paradigm shift in New Zealand. The rapid changes commenced by the former Liberal government reflect an environment where technology is also a key driver. Primary Health Care in Australia Primary health care could be described as the beggar-at-the-feast of health care services- always present yet peripheral to the main activities of health care and funded accordingly. The increasing investment in primary health care that is taking place across Australia has the characteristics of a 'lotto windfall' (it is still a question as to which division has been won). There is not only lack of agreement as to what primary health care is and so who should receive the prize, but lack of a policy framework to shape the spending of these winnings (McDonald et al, 2000, p. 3). The Health Inequalities Research Collaboration, launched in July 2000, is proposing to auspice and support a primary care network that involves consumers, researchers, state and federal government, practitioners and providers. The potential of this network could include not only enhanced collaboration but the development of a consensus around what primary health care should encompass. The World Health Organisation s (WHO) Alma Ata Declaration is a seminal statement about primary health care because it places centrally in the discourse notions of equity, community involvement, needs and standards as outcome measures. Actual health care services become tools and processes for achieving community well being. The Alma Ata Declaration describes primary health care as: essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford.it forms an integral part both of the country s health system, of which it is the central function and main focus. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. The Alma Ata Declaration ends by describing primary health care as a setting and as an entry point. Primary health care has tended to be defined by its scope, not with a forward vision or through its outcomes. It may be fair to say that operational definitions of primary health care have tended to focus only on the final point in the Alma Ata Declaration. A consequence of this in my view, has been a fragmentation of primary health care effort with services aimed at individuals rather than Health Issues, 2001, Number 67, pp. 28-32. 1

harmonising with community views generally, or with social-health views and concerns. Funding models have constrained the capacity to work coherently towards long-term goals for health. In practice, there is little coherent planning that puts individuals at the centre of a care process - predicting their needs and planning ahead for them. The existing practices of primary health care limit the capacity for accountability both to the broader community and to individual consumers. The development of the Primary Care Partnerships Strategy aims to address this deficit. The question of course, is will PCPs achieve what they are intended to do? The Changing Models of Primary Health Care in Victoria The new focus on the role and activities of primary health care are part of a world-wide phenomenon aimed at integrating social and health services with a view towards developing outcomes aimed at: efficiency; user satisfaction; better outcomes; addressing cross-system care problems; improving co-ordination of services; ensuring better access to services; and preventing cost-shifting. (Leutz, 1999, pp. 77-110) In Victoria, the former Liberal Government interpreted this as involving a heavy focus on efficiency, usually defined as delivering more services, more cheaply. Their strategy, The Primary Health And Community Support system, (PHACS) was established with an aggressive reform role. The PHACS redevelopment was part of a broad state government agenda that preferred larger community based agencies servicing population catchments of 300,000 or more (Raysmith, 1999). The PHACS redevelopment had two goals: 1. Forced service amalgamations and restructuring to simplify the purchasing process for government and to simplify local government from the perspective of the state. 2. Targeting of services to those communities most in need, including a shift of funds from metropolitan community health services to rural and outer metropolitan growth corridor community health services. Implied in both these activities was the capacity to define outcomes of health care coupled with the practice of population weighted funding. Initial problems with this approach, saw for example, services and funds transferred from the City of Yarra to the City of Boroondara because per head of population, Yarra looked over funded (City of Yarra, 1998, p. 2). In effect this meant a transfer of resources from a community with poor health, very poor social health status and the shortest male life span in the state (71.7 years), to a Boroondara community where men live on average for 77.26 years and which has a correspondingly good health status (Health Issues Centre, 2000). Boroondara certainly had a lack of services and realistically still needs support in developing health services commensurate with levels of need. The approach taken however, does not address real levels of need for either municipality. This suggests that the data, information, evaluation tools and decision-making processes of even the latest reform process, struggle with the task of supporting services that respond to need and advocacy around gaps in service provision. The overwhelmingly critical response from local government, community agencies and service providers to the PHACS redevelopment coupled with the change in Health Issues, 2001, Number 67, pp. 28-32. 2

state government in October 1999, brought the PHACS redevelopment to a halt. The redevelopment was reviewed (Raysmith, 1999) and then re-launched as the Primary Care Partnerships Strategy (PCPS). Primary Care Partnerships Strategy The current PCPS changes in Victoria include aims for developing Primary Health Care strategies and practices that are: 1. Inclusive of consumers and the community (including involvement of consumers in prioritisation of health issues, planning and evaluation roles). 2. Integrative of a range of service providers (in a collaborative framework). 3. Able to address the issues of social determinants of health (including a focus on risk factors and reducing the incidence of preventable illness). 4. Able to address the diversity of the Victorian community (including cultural, ethnic, religious, linguistic and rural and metropolitan specific needs). 5. Focussed on government s role in planning, not purchasing. (Aged, Community and Mental Health Division, 2000a, p. v) This represents a major broadening of the conceptualisation of primary health care in this state. Primary health care services are required through this series of functions to become a public or population health service deliverer. It also places at the centre of primary health care policy some of the ideas of the Alma Ata Declaration. Primary Health Care Alliances include: local government; community health; Divisions of General Practice; Aged Care Assessment Service; and Royal District Nursing Service or its equivalent in rural or regional Victoria. In addition, sign-off is needed from at least two of the following specialist service providers operating in the alliance area concerned: psychiatric disability support service; drug treatment service; ethno-specific service; women's health service; and sexual assault service. Some of these smaller agencies have expressed concern that they do not have as strong a voice as the larger and more mainstream services, in the structure of the PCP alliances. The role of statewide groups such as the Asthma Foundation and their input into 32 individual PCPs is also unclear. Likewise the role of the consumer is open to interpretation in each PCP. It is not clear how they will input in to governance and project development as the level of conceptualisation varies greatly across PCPs. As a rule, PCPs have been formed covering catchment areas of two to three municipalities. There is debate about how effective one PCP can be in terms of addressing local need and facilitating natural partnerships of interests. Natural communities of interest are still being discounted in preference for large population catchments. There are around 1,000 agencies and groups involved as partners in PCPs across the state. Some PCPS have 60 agencies as alliance members, others have up to 100. These PCPS alliances have also been created by the legacy of the PHACS redevelopment. The PCPS alliance Health Issues, 2001, Number 67, pp. 28-32. 3

partnerships tend to reflect Department of Human Service regional boundaries and the Metropolitan Health Service catchments. This is partly driven by what has already been invested in existing relationships and patterns of data collection. Planning and Measuring Outcomes There is a major desire to measure outcomes of PCPs but relatively rudimentary tools currently available to do so. These reform processes are heavily dependent on the generation of information and data in order to define need and measure outcomes. In some PCP alliance groupings, community organisations and local government have agreed to harmonise their planning cycles. All PCP alliances are required to base their service planning on information generated through the local government Municipal Public Health Plan (MPHP) process. Consistency in health indicators and subsequent data collected is problematical where PCPs cover two or more local government areas. Mechanisms and incentives for working towards common and generic data sets across all local government areas are undeveloped. Consumer s traditionally have had little say in the types of data collected to indicate need and while there is such a patchwork approach this is likely to remain so. However work is underway to identify the types of data needed for effective MPHPs and how this should be collected (Ruth & Sulaiman, 2000). It is clear that this area needs to be better and specifically funded in order to be successfully completed. Another concern with data can be seen in the situation of many inner city municipalities. These local government areas can have population turnovers of in excess of 50% as a norm, every five years. However, ABS census data only becomes available five years after the collection year, making following and planning for an increasingly mobile Australian population difficult (Health Issues Centre, 2000). Population health needs identified at this local level help set the priorities for resource allocation decisions and bids for funding made via Community Public Health (CPH) plans generated at the level of the PCP alliances. (It is possible that PCPs will bid to become local fund holders, similar to models in the United Kingdom and NSW.) Community Health Plans are the regional service planning and co-ordination tool and provide the tool for defining and managing service partnerships. Overtime the integrated planning and service strategies generated and agreed to within each PCP alliance are intended to influence individual provider service plans (Aged, Community and Mental Health, 2000a, p. 16). In the earliest stages of the PCP developments, Community Health Plans will, be expected to focus on: 1. Service planning (including health promotion and integrated disease management). 2. Service coordination - coordinating local infrastructure development such as information management and referral. 3. Service partnerships - defining how the partnership will implement the Community Health Plan. Specific funds and training provisions have been allocated to health promotion development. Other funds are available for discrete demonstration projects on a competitive basis. At this time, this means each alliance identifying a few priority areas in their PCP area and developing co-ordinated approaches to dealing with them. PCPS remain at heart, like the PHACS redevelopment, a resource allocation tool. As they stand, funding arrangements will not solve the population weighting dilemma. In addition PCPS, while they consist only of services funded through Health Issues, 2001, Number 67, pp. 28-32. 4

one section of the Victorian Department of Human Services will not be able to do more than reflect a 'silo' approach to primary health care. For instance initiatives in older person s health and mental health are not necessarily synchronised with the PCPs Strategy. Another major challenge is to engage Divisions of General Practice who are funded federally, see few immediate gains to their involvement and to whom the issue of GP remuneration in community activities is a vexed issue and not dealt with to their satisfaction by PCPs. Access Lack of equity in accessing primary health care services has been a critical driver of these developments. However rather than increasing services as such, PCPs are seen as the vehicle to reorient and redesign the system by investing in building capacity, although operationalising this abstract ideal is less defined. PCP alliances will therefore be expected to demonstrate a responsive approach to communities such as: Koori people; homeless people; people from culturally and linguistically diverse backgrounds; people with disabilities; and people living in rural or remote areas. (Aged, Community and Mental Health Division, 2000a, p.14) The draft policy framework for access to PCP brokered services is currently being developed by the Department of Human Services with stakeholders. (Aged, Community and Mental Health Division, 2000b). The intent is to develop a more streamlined assessment process with broadly agreed eligibility criteria, stronger referral processes and a view towards limiting the number of times that a consumer must tell their story. It is hoped, this 'better' access process will reduce the risks accrued by consumers who are not able to access services they need in a timely fashion. Assessment and access as presented in the PCPs program potentially raises expectations of consumers. There actually needs to be enough services that are readily available, in order for any improvements from streamlined assessments to occur. Assessment can also keep people out of services that they may well want and be entitled to. Assessment is also an ongoing, cyclical activity that through co-ordination, referral and other strategies should improve the care process. As currently described, the BATS - Better Access To Services process suggests a linear approach that has more to do with funding streams for 'specific', 'complex' and 'comprehensive' types of needs (Aged, Community and Mental Health Division, 2000b). Consumers often identify themselves as having specific needs while needing complex and comprehensive care. Consumers and PCPs At the heart of changes to health care and government service delivery in Victoria, has been emphasis on the notion of consumers as active participants in their care and the community as key stakeholders. The state government requires PCPs to: engage with local communities...[as a]...key aspect of the alliance's work... (Aged, Community and Mental Health Division, 2000a, p. 14) Good Primary Health Care strategies depend on the recognition, not a glossing over, of the diversity of the community and consumers. They also depend on the inclusion of consumers, their perspectives and concerns in primary health care planning and service delivery. It is not yet clear how this will be done effectively. Health Issues, 2001, Number 67, pp. 28-32. 5

Conclusion Unless there is attention paid to issues of equity and fairness, not only will consumers still be outside the process of primary health care delivery but the PCPS reforms will have only been about the traditional settings and entry points of primary health care. The success of the changes in primary health care in Victoria remain to be seen. While the jury is still out, there are issues that can and should be addressed. There needs to be a thoughtful stance taken that recognises that outcomes depend on what is prioritised and who gets to set these priorities. The PCPS reform will only have a limited impact if it becomes captured by a focus on an administrative reform agenda. Administrative reform in health service policy and delivery is a necessary parallel but not a substitute for genuine change in primary health care delivery that provides measurable improvements in equity, community involvement and wellbeing. Merrian Oliver-Weymouth is a Policy Officer at Health Issues Centre. References Aged, Community and Mental Health Division, 2000a, Going Forward: Primary Care Partnerships, Department of Humans Services, Victoria. Aged, Community and Mental Health Division, 2000b, Primary Care Partnerships: Better Access to Services: Draft Policy Framework for Discussion, Department of Human Services, Victoria. City of Yarra, 1998, Primary Health Care in Yarra: An Overview Paper for the Service Plan for PHACS Redevelopment in the City of Yarra, City of Yarra. Health Issues Centre, 2000, Our Community: A Report on the Community Profile and Health Status of the City of Yarra, City of Yarra. Leutz, W., 1999, Five laws for integrating medical and social services: lessons from the United States and the United Kingdom, The Milbank Quarterly, Vol. 77, No. 1, pp. 77-110. MacDonald, J., Harris, E. and Furler, J., 2000, Primary Health Care: Health Equity Research and Development Network Discussion Paper. Raysmith, H., 1999, Report of the Review of Primary Health Redevelopment, Department of Human Services, Victoria. Ruth, D. & Sulaiman, N., 2000, Public Health Research Project: Hume Moreland: Phase 1 Use of Data in Community Health Planning, North Western Health & Department of Community Health. Health Issues, 2001, Number 67, pp. 28-32. 6