Introduction
Primary health care (PHC) is the cornerstone of Australia’s healthcare system, acting as the first point of contact for individuals seeking health services. It plays a crucial role in connecting communities to essential healthcare, facilitating access to specialized services, and coordinating care for individuals with complex and chronic health conditions. For primary health care to function effectively, seamless integration is paramount, both within its various components and with the broader healthcare ecosystem, including hospitals and community services. This article examines the current state of primary health care integration in Australia, analyzes the impact of ongoing and proposed reforms, and identifies areas for further enhancement to achieve effective and sustainable integration.
The Australian Healthcare Landscape: Context for Primary Health Care
Australia, a vast continent with a relatively small population of 21 million, presents unique challenges for healthcare delivery. A significant majority (70%) of Australians reside in major cities, while substantial proportions live in regional (14%), rural (14%), and remote areas (3%). This geographical distribution necessitates diverse approaches to healthcare design and delivery, each with specific implications for primary health care integration.
The population’s diversity further complicates healthcare provision. Nearly a quarter of Australians were born overseas, 16% speak a language other than English at home, and there is a growing refugee population. Indigenous Australians, while constituting a small percentage (2.5%) of the population, face a stark health disparity, with a life expectancy significantly shorter (17 years) than non-Indigenous Australians. While Australia is generally affluent, pockets of social and economic disadvantage exist, requiring targeted healthcare strategies.
These demographic and geographic factors shape the challenges of primary health care integration. In urban settings, the primary concern is coordinating care within a complex network of generalist and specialist services, often with limited intercommunication. In rural and remote areas, the challenge lies in maximizing the impact of scarce resources to provide adequate population coverage and establishing effective links with distant specialist services. For minority groups with unique health needs, the focus shifts to coordinating specialized programs designed to address those needs and integrating them with mainstream healthcare services.
Several features of the Australian healthcare system significantly influence primary health care and its integration:
Divided Responsibilities: Healthcare responsibility is shared between the Commonwealth (federal), state, and local governments. The Commonwealth government, through Medicare, funds medical services outside public hospitals and some allied health services. States and territories manage public hospitals and most public and community health services, funded through a combination of Commonwealth grants and state taxes. Local governments play varying roles, sometimes providing community nursing, community care, and public health services.
Significant Private Sector Involvement: The private sector is a major healthcare provider, accounting for a substantial proportion of hospital admissions and most medical services outside public hospitals. A considerable portion of the population holds private health insurance, traditionally for hospital, dental, and allied health care. However, private health insurers are increasingly venturing into primary health care through preventive and chronic disease management programs.
Health Workforce Shortages and Distribution: Australia faces a significant shortage of health professionals, particularly in outer urban, rural, and remote areas. This maldistribution is exacerbated by the ability of Medicare-eligible professionals to establish practices wherever they choose. Workforce shortages increase the urgency for efficient service delivery, often hindered by rigid professional and sectoral boundaries.
Fragmented Electronic Medical Records: A lack of a unified approach to electronic medical records across sectors and jurisdictions poses a major barrier to health service integration. Incompatible systems and differing privacy regulations complicate health information exchange. The National E-Health Transition Authority is currently working to address this issue.
Components of Primary Health Care in Australia and Integration Challenges
Australian primary health care is delivered through four main types of services and providers:
-
General Practice: Typically organized as small businesses or sole practices, though corporate ownership is growing. GPs operate as independent professionals with autonomy over practice location, patient selection, and fee setting. Practice nurses are increasingly common, particularly in rural areas. Divisions of General Practice, member organizations funded by the Commonwealth, support quality improvement, integration, and population health initiatives within geographical areas.
-
Community Health Services: The second largest component of PHC, funded by states and territories. Service range, decentralization, and links to hospitals vary significantly. Community health adopts a broader PHC approach than general practice, emphasizing population health and health promotion. Core services include community nursing, allied health, and specialized services like early childhood, mental health, and substance abuse support. Hospital avoidance and chronic disease management are growing priorities.
-
Private Allied Health Services: Pharmacists, physiotherapists, dieticians, podiatrists, optometrists, and exercise physiologists operate independently, similar to GPs. They lack the organizational support structure of Divisions of General Practice.
-
Aboriginal Community Controlled Health Services (ACCHSs): Over 140 ACCHSs exist, varying in structure and service provision, which may include GPs, allied health professionals, and Aboriginal health workers. These community-run organizations often prioritize preventive healthcare and are represented by state/territory and national peak bodies like the National Aboriginal Community Controlled Health Organisation (NACCHO).
Emergency departments often serve as a point of first contact, although this is generally discouraged as a primary health care pathway. After-hours GP clinics have been established in some areas to address this.
The structural arrangements for these services contribute to the complexities of primary health care integration in Australia.
Alt Text: Table outlining the organization of Australian primary health care, detailing sector, funding source, mode of payment, and budget type for General practice, Community health, Private allied health, and Aboriginal Community Controlled Health Services. This table highlights the diverse funding and operational models within the Australian primary health care system.
Primary medical care coordination largely occurs through general practice and ACCHSs, or nurse practitioner clinics in remote areas. Access to general practice is widespread, with a high proportion of Australians reporting a ‘medical home’. GPs act as gatekeepers to specialist medical services, facilitating referrals and established networks. Coordination with specialists is generally effective. However, coordination with other primary care components is often more challenging. Unlike some countries, community-based nursing and public allied health services are rarely integrated within general practices. Fee-for-service models may not adequately support care coordination activities, although programs like the Enhanced Primary Care Program offer some support for chronic and complex care coordination. The absence of mandatory patient registration can also create ambiguity in ongoing care management and coordination responsibilities.
Relationships between general practice and community health are complex, marked by cultural and role differences, despite local coordination efforts facilitated by Divisions of General Practice. Fixed budgets can limit community health’s capacity to collaborate with general practice. Collaboration between general practice and private allied health providers is often smoother due to shared private practice cultures. The introduction of Medicare benefits for private allied health services for chronic conditions has incentivized greater collaboration.
Hospital relationships vary across primary health care. Community health and public hospitals, often under state/territory government control, experience greater coordination, particularly in areas like hospital demand management. General practice, being structurally independent, relies on local factors for effective interaction with hospitals. Local initiatives, often through Divisions of General Practice, address shared concerns like emergency department pressures and hospital avoidance. State health departments are increasingly promoting formal care systems involving primary health care and hospitals, such as the Victorian Hospital Admission Risk Program (HARP).
Social care integration is also complex, with responsibilities divided between Commonwealth and state/territory governments and services delivered through various agencies. Home and community care and early childhood intervention are areas of focused coordination efforts. The Home and Community Care (HACC) program, a joint initiative, provides support services to older adults and people with disabilities, often involving community health services. Early intervention programs like Families NSW and Best Start in Victoria aim to integrate health and related services for early childhood development. However, integration with general practice in these social care areas remains limited.
Initiatives to Enhance Primary Health Care Integration
While Australia performs well in providing access to a ‘medical home’ and GP-coordinated care, structural barriers impede broader primary health care integration, particularly in service planning and coordinated responses to health challenges. Current and proposed initiatives address three key integration challenges:
- Lack of Clear Policy Direction: Fragmented responsibilities hinder cohesive policy.
- Poor Service Planning Integration: Incompatible funding and accountability, and weak regional structures, contribute to planning silos.
- Difficult Access to Multidisciplinary Care: Weak links between general practice, community health, and private allied health limit coordinated care, especially for chronic conditions.
Primary Health Care Policy Reforms
Australia currently lacks a comprehensive national primary health care policy. While some cross-jurisdictional policies exist for specific health issues through the Council of Australian Governments (COAG), and framework agreements address Aboriginal and Torres Strait Islander health, a holistic primary health care policy is absent.
The Commonwealth government exerts some influence through Australian Health Care Agreements with states/territories, but these historically focused on hospital performance. Government bodies like the National Health and Hospitals Reform Commission and the Primary Care Taskforce have proposed reforms. A key recommendation is for the Commonwealth to assume responsibility for all primary health care policy and funding to improve integration. The Primary Health Care Taskforce also advocates for a national primary health care policy.
Centralizing primary health care policy and funding under a single level of government could significantly reduce integration barriers and enable new service models. However, the impact hinges on the comprehensiveness of the approach, decentralization of planning and coordination, funding flexibility, and professional adaptability.
Service Planning and Development Initiatives
Currently, service coordination within primary health care is largely voluntary, leading to commitment and capacity challenges. Local coordination occurs between Divisions of General Practice and state-funded services, with limited private allied health involvement. Memoranda of Understanding often underpin these arrangements, but a lack of performance and accountability frameworks can limit their effectiveness.
Some states and territories have established regional networks to improve primary health care integration. Victorian Primary Care Partnerships (PCPs), established in 2000, are a leading example, fostering collaboration among community health, local government, general practice, NGOs, and hospitals. PCPs focus on improving service coordination to reduce hospitalizations and have been supported by state government funding and resources. Queensland is adopting a similar model, and South Australia is developing primary health care networks through its GP Plus strategy.
This voluntary approach aligns with the Australian healthcare system’s decentralized nature, accommodating diverse jurisdictions and maintaining service autonomy. Evaluations of Victorian PCPs indicate improved care coordination, especially within state-funded services. However, engaging general practice and impacting service planning beyond health promotion has been less successful.
Both the National Health and Hospitals Reform Commission and the Primary Health Care Taskforce propose regional primary health care organizations for planning and coordination, potentially evolving Divisions of General Practice into broader Divisions of Primary Care. The Primary Health Care Strategy Taskforce envisions “regional level organisations” with responsibilities spanning planning, coordination, program delivery, and potentially local funding allocation.
Centralized primary health care governance could strengthen these regional networks and facilitate genuinely integrated planning, especially with devolved funding responsibilities. However, this necessitates significant cultural shifts, particularly in the private sector, and substantial capacity building for managing organizations and personnel.
Enhancing Access to Coordinated Multidisciplinary Care
Limited data exists on multidisciplinary care access and appropriateness in Australia. Barriers include insufficient public funding for allied health and care coordination challenges.
The Commonwealth government introduced the Enhanced Primary Care program in 1999 to improve multidisciplinary care access for chronic conditions. This included Medicare Benefits Schedule (MBS) items for GP involvement in care planning and incentives for practice infrastructure. In 2005, MBS fee-for-service payments were extended to private allied health professionals for chronic disease patients with GP referrals. Divisions of General Practice have also received funding to improve GP access to allied health through various models. Programs like the More Allied Health Services program and Access to Allied Psychological Services Program target specific populations and conditions.
More recently, integrated primary health care service programs have emerged. The national ‘GP Super Clinics’ initiative aims to establish centers bringing together various healthcare professionals. State initiatives like HealthOne NSW and South Australian GP Plus Centres integrate general practice with community health and sometimes private allied health and community care services. These centers face challenges in cross-sector collaboration, governance, and care model development, and are still affected by varied funding and accountability systems.
The National Health and Hospitals Reform Commission and Primary Health Care Taskforce advocate for continued development of integrated services, active care coordination, and individual electronic health records. Proposed changes include clearer patient handover protocols and trials of voluntary patient enrolment with primary providers for complex needs. Collaboration with non-health services, while less emphasized, is recognized as important, particularly for complex mental health needs, as reflected in the COAG mental health strategy, which includes care coordination between health, housing, and education.
Alt Text: Table describing the main components of Australian primary health care, including General practice, Community health, Private allied health services, and Aboriginal Community Controlled Health Services, highlighting their organizational structures and service delivery models within the Australian healthcare system.
Discussion: Towards a More Integrated Primary Health Care System
Australian primary health care remains structurally fragmented, characterized by a mix of public and private services, diverse funding jurisdictions, and varied funding arrangements. While service providers have developed workarounds to navigate these discontinuities, this fragmented system is inefficient and inequitable and hinders integrated service development and population-focused healthcare.
Structural reforms are essential to enable disparate primary health care components to function as a cohesive system. Current reform processes offer a promising opportunity for progress. Recommendations from the National Health and Hospitals Reform Commission and the Primary Care Task Force encompass key elements for improvement: unified governance under a single level of government, a guiding national primary health care strategy, regional organizations for service planning, and voluntary patient registration to strengthen GP-patient relationships. Flexible funding models, payments aligned with chronic and complex conditions, and enhanced information infrastructure are also crucial enablers.
Political realities, professional interests, workforce shortages, and economic conditions will shape the implementation of these reforms. Careful change management and realistic expectations are necessary. The proposed reforms offer a foundation for service funders, developers, and providers to collaboratively design more integrated healthcare models at regional and local levels.
Beyond structural integration, developing a more population and community-oriented primary health care system is crucial. Australian primary health care currently leans towards a professionally oriented model, focused on individual patient care rather than comprehensive population health and equity. Reform documents also tend to reflect this professional orientation. Achieving comprehensive primary health care necessitates integrating both professionally and community-oriented approaches. The proposed reforms, while professionally focused, represent a significant and welcome step towards a more integrated and effective primary health care system in Australia.
References
[1] Starfield B: Primary Care: Balancing Health Needs, Services, and Technology. Oxford University Press; 1998.
[2] Australian Institute of Health and Welfare: Australia’s Health 2008. Canberra: AIHW; 2008.
[3] Health Insurance Act 1973 (Cwlth).
[4] Duckett S: Medicare: An Australian success story. Aust J Public Admin 2004, 63(1):70-83.
[5] Australian Institute of Health and Welfare: Hospital Utilisation and Costs 2006-07. Canberra: AIHW; 2008.
[6] Australian Prudential Regulation Authority: Quarterly Private Health Insurance Statistics March 2009. APRA; 2009.
[7] Dowden M, Moyle W, Christie M, et al: Chronic disease management programs: the views of Australian health fund executives. Aust Health Rev 2008, 32(3):449-459.
[8] Joyce C, McNeil J, Stoelwinder J, et al: More doctors, but not enough? Trends in the medical workforce in Australia, 1996-2006. Med J Aust 2008, 189(2):96-100.
[9] National E-Health Transition Authority. http://www.nehta.gov.au/
[10] Department of Health and Ageing: National Primary Health Care Strategy. Canberra: DoHA; 2009.
[11] Australian Institute of Health and Welfare: The general practice workforce in Australia: activities, capacity and composition 2007. Canberra: AIHW; 2008.
[12] Divisions of General Practice Program. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-divisions
[13] Australian General Practice Network. http://www.agpn.com.au/public/
[14] Britt H, Miller GC, Knox S, et al: General practice activity in Australia 2007-2008. General practice series no. 23. Canberra: AIHW; 2008.
[15] Commonwealth Department of Health and Aged Care: National Community Health Service Profile. Canberra: CDHAC; 2000.
[16] Harris MF, Furler J, Harris E, et al: Models of primary health care for diabetes in the community setting. Diabetes Res Clin Pract 2008, 82(Suppl 1):S79-S87.
[17] National Aboriginal Community Controlled Health Organisation. http://www.naccho.org.au/
[18] Schoen C, Osborn R, Doty MM, et al: In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. Health Aff (Millwood) 2009, 28(1):w1-w16.
[19] Willis E, Harvey J, Wise M, et al: Medical specialists and general practitioners in Australia: evolving or dissolving relationships? Aust Health Rev 2004, 28(3):327-339.
[20] Enhanced Primary Care Program. http://www.health.gov.au/internet/main/publishing.nsf/Content/health-epc-program
[21] вигляді S, Jackson C, Bhattarai GR, et al: Evaluation of the Enhanced Primary Care (EPC) program for older Australians. Canberra: Department of Health and Ageing; 2005.
[22] Lewis J,予 C,予 M, et al: Patient registration in Australian general practice: issues and options. Med J Aust 2004, 181(2):88-91.
[23] Medicare Benefits Schedule. http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Home
[24] ួន S,予 M,予 C, et al: Community nursing in Australia: current issues and future directions. Aust J Adv Nurs 2007, 25(1):44-53.
[25] Valenti L, Banks E, Singh N, et al: General practice-hospital relationships: a systematic review of the literature. Med J Aust 2007, 187(1):23-28.
[26] Victorian Department of Human Services: Hospital Admission Risk Program (HARP). Melbourne: DHS; 2009.
[27] Home and Community Care Program. http://www.health.gov.au/internet/hoc/publishing.nsf/Content/ageing-hacc-index.htm
[28] Families NSW. http://www.community.nsw.gov.au/DOCS_PUBLIC/CENTRAL_WEBSITE/Programs_and_Services/Families_NSW/programs_families_NSW.htm
[29] Best Start. http://www.education.vic.gov.au/ecsmanagement/participation/beststart.htm
[30] Hayes A, Watson L, 셩 R, et al: Evaluation of the Families First Program. Sydney: NSW Department of Community Services; 2007.
[31] Broerse JE, Burger EH, Schilderman JB, et al: Integration of public health and primary care: experiences and challenges in eight countries. Eur J Public Health 2007, 17(1):18-24.
[32] Council of Australian Governments: National Action Plan on Mental Health 2006-2011. Canberra: COAG; 2006.
[33] National Chronic Disease Strategy. http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pqpc-ncds
[34] Council of Australian Governments: National Framework for Aboriginal and Torres Strait Islander Health 2003-2013. Canberra: COAG; 2003.
[35] National Health and Hospitals Reform Commission: A healthier future for all Australians – Interim Report. Canberra: NHHRC; 2008.
[36] National Primary Health Care Strategy Taskforce: National Primary Health Care Strategy – Discussion Paper. Canberra: DoHA; 2009.
[37] Victorian Department of Human Services: Primary Care Partnerships. http://www.health.vic.gov.au/pcps/
[38] South Australian Department of Health: GP Plus Health Care Centres. Adelaide: DoH; 2009.
[39] Harris MF, មួយ E, 予 P, et al: Evaluation of the Victorian Primary Care Partnerships program: final report. Sydney: Centre for Primary Health Care and Equity; 2008.
[40] Harris MF, មួយ E, 予 P, et al: Evaluation of the Victorian Primary Care Partnerships program: interim report. Sydney: Centre for Primary Health Care and Equity; 2006.
[41] មួយ E, Harris MF, 予 P, et al: The role of Primary Care Partnerships in health promotion in Victoria, Australia. Health Promot Int 2008, 23(4):356-363.
[42] Australian Institute of Health and Welfare: Medicare Australia statistics: allied health services. Canberra: AIHW; 2009.
[43] More Allied Health Services Program. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-moreahs
[44] Access to Allied Psychological Services program. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mental-boimhc-aaps
[45] មួយ E, Harris MF, 予 P, et al: The role of Divisions of General Practice in improving access to allied health services. Aust J Prim Health 2009, 15(2):148-156.
[46] GP Super Clinics Program. http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pcd-programs-gpsuperclinics
[47] HealthOne NSW. http://www.health.nsw.gov.au/healthone/
[48] GP Plus Health Care Centres. http://www.gpsa.sa.gov.au/DesktopDefault.aspx?tabid=171
[49] Lamarche PA: Primary health care in industrialized countries: from theory to practice. Can J Public Health 1986, 77(Suppl 1):55-67.
