Abstract
BackgroundSince the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities.DiscussionIn this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services.SummaryWe conclude that there has been an evolutionary approach to divisions' development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions' direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions' role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations.
Highlights
Since the late 1980s, there has been evidence of an international trend towards more organised primary care
Summary: We conclude that there has been an evolutionary approach to divisions' development and they appear embedded as geographically-based planning and development organisations within the Australian primary health care system
This can be seen on the one hand as a sensible and pragmatic approach to facilitating the development of general practitioners (GPs) groupings in a context that was firmly rooted in the private business/ independent model of general practice, recognising that it could be counter-productive for the government to be seen to be dictating terms and trying to contract with GPs outside the usual arrangements for agreeing practice fees, something that would be unthinkable in the Australian context
Summary
This is despite evidence from its own co-ordinated care trials carried out in the 1990s (trials that involved primary care budget holding by groups of professionals charged with managing care for people with chronic conditions and complex needs), that concluded that fund-holding had the potential to improve patient outcomes if it was implemented with appropriate incentives for professionals, prior community debate, and careful monitoring and evaluation [20] Reasons for this reluctance on the part of government might include: research evidence that suggests that primary care-based purchasing has higher transaction costs than larger area funders [1,12]; the complexities inherent in pooling resources across different levels of government (national and state/territory); the power of the Australian medical establishment and its traditional opposition to fundholding on the basis that it draws doctors into health care rationing; manifest unevenness in capacity across the divisions network to take on such a role; and reticence on the part of federal government to allocate large sums of public money to organisations made up of private sector GPs with whom they have no contractual relationship. There has been strong interest among some divisions to implement such programmes, government appears to be unwilling to agree to arrangements that would allow division-government sharing of the financial benefits of better prescribing, in part needed by divisions to fund the programmes
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