The delivery of care in the community is increasingly seen as vital in terms of patient outcomes, health promotion, and the prevention of illness in society. The primary care practitioner is generally the first point of contact with the healthcare system, and current reforms in primary health care—as well as the dynamic nature of society and social preferences—have seen the roles of general practice and general practitioners in Australia undergo a transformation. Achieving results in health outcomes is going to require the implementation of innovations such as multi-professional primary healthcare teams,1 technological innovations, and procedural reform. The question remains—how are such changes most effectively implemented, and at what stage are we currently in this “reformation”?
Reformation and innovation
Reforms in primary care are, and will continue to be, an important part of the innovations that will produce positive patient outcomes. Population-based approaches in primary care, coupled with greater cross-sector collaboration and consumer participation, have been touted as being able to deliver truly comprehensive primary health care.2 Culturally appropriate and accessible services, funding and staffing structures that allow flexibility of service provision in terms of location, appointment times, and the range of staff providing services are suggested as necessary to support such reforms and allow the successful transformation of primary care services.2 Treatment of patients will need to take into account the patients’ needs, culture and preferences, and will necessitate the need for healthcare professionals to work together and facilitate crossdisciplinary clinical care to achieve a better solution to the patients’ problems.3 This includes issues that relate to public interaction with medical practitioners, including “trust” of medical practice and new innovations in health care.4
Disciplinary-specific challenges within primary health care are also appearing. In Australia, the need for care of the dying will accelerate in the foreseeable future. Australia’s population is ageing, and with this will come a significant expansion in chronic illness and death from frailty and nonmalignant disease. This will exacerbate the challenge to provide palliative care for all people who need it, however 25 per cent of Australian general practitioners state they are not willing to provide palliative care.5,6 Worryingly, such unwillingness is suggestive of problems in the infrastructure and resourcing of general practice in Australia, and dictates that further investigation is required to identify how support may be provided for primary health care in this area. That is not to say change has been absent in recent years, with a host of innovations being instituted in Australia since the 1990s: national practice accreditation, regional integration, improved access to care, focus in quality improvement and information technology adoption, among others, have developed the Australian primary healthcare system into a more integrated and comprehensive service. However, there are still challenges such as the need to strengthen the primary care workforce and the increasing number of patients with chronic diseases and obesity.7
Innovations in primary care are going to be necessary in a wide range of areas, from education to economics, access to health services, and in the use of technology. Writing about the scope and necessity to innovate in primary care, Jiwa argues that both the needs of the patient and the practitioner will drive innovation in the future.8 He suggests three issues are likely to be the primary focus for research and development—increasing access to health care, maintaining wellness in the light of the growing incidence of lifestyle-related morbidity, and reducing the cost of treatment. It is how these aims are best achieved that is currently proving problematic for primary healthcare providers.
Access to best practice in primary health care is achieved with multiple and linked strategies targeted to different levels of the healthcare system, with strategies to improve patient access to primary health care playing a key role in the form of incentives, the encouragement of multidisciplinary care, and community programs.9,10 However, care will need to be taken in how such innovations are introduced into the clinical setting, with evidence from prior investigations indicating patients are not always managed in a way that is consistent with guidelines provided to clinicians.11 The clear challenge is to devise innovations that make it more likely that practitioners will offer evidence-based care. Such innovations need to be consistent with how practitioners deliver care in the general practice consultation,11 while realising that translation of innovation into the clinic can be viable using resources that need little investment, and that multi-modal approaches have great potential.12
Clinical decision-making has the potential to be enhanced with the use of electronic devices equipped with programmes and algorithms that aid diagnosis. However, the use of such electronic support of clinical decisions must go hand-in-hand with the development of clinical guidelines, as well as the integration of electronic health records to the workflow of clinicians, to achieve better quality in health care and reduce costs.13 Any such change must also bear in mind that there is not a common way in which general practitioners understand clinical practice, and how specific problems on consultations can affect the adherence to certain discourses.14The implementation of healthcare improvement with a planned system change can be deficient in reality, mostly because the complexity of challenges in primary care needs a more flexible approach,15 suggesting that enthusiasm for development of these resources needs to be weighed against the potential for disengaging a potentially technology-weary public. Guidelines for such technology will become more important with the increase in the number of innovations available for use.8
Technology
Technology is an important issue in primary care, and is becoming increasingly so with the affordability and use of mobile devices that allow a 24/7 connection to the Internet. Patients now have access to an ever-increasing number of health sites and information. How technology will drive changes in primary health care in the future is yet to be determined: digital technology and changes in patient expectations have had varying impact on a profession that continues to adapt to patient needs as well as the evolving attitudes of practitioners.7
Patient decision aids, despite the new technologies available from the last 30 years, are still widely underused and do not cover some individual needs.16 However, it is suggested that mobile phones, tablets, and other digital technologies can improve access to information and provide a more personalised patient profile that will help decision making.16 Databases on patient decision support can also be helpful to clinicians by facilitating decision-making, aiding policy makers in the development of cost-effective decisions, and to software and systems developers who can then improve the design of patient decision aids.16 Evidence of this has been demonstrated through the use of webbased health management systems, where patients using personally controlled health management systems have been shown to use health service providers more than nonusers in some settings, demonstrating that health management systems can be integrated into routine health service delivery systems as an effective tool for prevention.17
New innovations and technology certainly have the potential to have a positive impact on patients, with SMS appointment reminders, websites that give support to both clinicians and patients in remote areas, or teleconferencing being examples of how new innovations can aid primary health care.18 It is suggested that digital technology may also assist the primary care provider and that this has the potential to positively impact patient outcomes,18 with support aids, electronic referral tools, and other novel processes also having the potential to improve diagnostic or therapeutic aids. Yet technology is not limited to web resources: novel innovations can be tested with a reference to simulated patients, offering the scope to test ideas before they are deployed in randomised clinical trials.19 More recent work has explored the use of video vignettes delivered over the Internet to generate and explore hypotheses in general practice.20
Conclusion
Reform in Australia’s primary healthcare sector, principally in relation to the use of technology and innovation, will continue to play a vital role in altering the way primary health care is delivered in response to the dynamic and unpredictable nature of society. Technology and innovation will continue to have a leading role in the provision of healthcare services, and certainly has the potential to improve health care and provide healthcare benefits in the future, with multi-disciplinary teams and improvements in access to health care also contributing to better patient outcomes. However, whether changes in infrastructure and service delivery will be developed and implemented in time to meet the challenge of the predicted explosion in areas such as chronic disease and palliative care remains to be seen. The necessary funding for reforms in this area should not distract from such an investment—data indicate that investing in primary health care has clinical and economic benefits1—and one thing is certain: sustainable, innovative solutions are required to further support primary healthcare reformation in the very near future.
Footnotes
PEER REVIEW
Commissioned. Externally peer reviewed
CONFLICTS OF INTEREST
JC is the deputy editor of the AMJ.
Please cite this paper as: Cornwall J. The future of primary healthcare in Australia: Where to from here? AMJ 2014, 7, 2, 78-80.http//dx.doi.org/10.4066/AMJ.2014.1959
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