National Primary Health Care Strategic Framework

Strategic Outcome 1: Build a consumer-focused integrated primary health care system

Page last updated: April 2013

Primary health care services are integrated and coordinated within the primary health care sector and across the wider health system. The services are tailored to meet consumer needs and preferences and are appropriate to the needs of specific population subgroups.

Potential Actions

1.1 Establish formal planning and engagement protocols between Medicare Locals and Local Hospital Networks, in partnership with consumers and other providers, to develop joint service plans and work together to ensure the delivery of services that achieve the best outcomes for individuals and the wider community.

Medicare Locals and Local Hospital Networks will work with local consumers and providers to develop joint plans for the design and delivery of integrated, coordinated and responsive services at the local level. This will bring together vital data, information and knowledge from the primary and acute health sectors, consumers, providers and the broader social service system on the needs and priorities for local communities.

Joint planning and decision-making will provide a foundation that supports consumers in navigating the health system more effectively, and directs resources to the services which achieve the best possible outcomes - regardless of where those services are delivered or who funds them. Joint planning will also engage consumers and providers at the local level.

This engagement of key players in joint planning will also assist in the development of local health solutions to achieve shared performance indicators as agreed under the COAG Performance and Accountability Framework. Top of page

1.2 Identify the health needs of individuals within different population groups and develop evidence based health care support and interventions, with a focus on prevention, health promotion, self-care and intervention.

Individuals within different population groups will require different types of support from the health system. Risk varies among population groups according to a range of factors including age, sex, cultural background, geographical location, socio-economic status, past experience and family history, in addition to lifestyle factors, such as smoking, alcohol use, exercise and diet.

A relatively simple and tested model to stratifying risks within the population is to identify known experience of the health system, as well as modifiable group behaviours:

  1. people who are relatively high users of the hospital system (a small percentage of the population use a high proportion of hospitalisations);
  2. those who are at risk of becoming high users of the hospital system (those with complex chronic co-morbidities e.g. diabetes, coronary artery disease, chronic obstructive pulmonary disease, other respiratory disease, and hypertension);
  3. those with multiple modifiable risk factors (overweight or obese, smoking, excessive alcohol, risky sexual behaviours, etc.); and
  4. those with no or limited modifiable risk factors. Top of page
Interventions for these various groups should then be designed to match need, based on evidence of what works. This could rank, for example, from high level interventions such as case management and care coordination, to secondary prevention for those with chronic conditions, lifestyle modification, primary prevention, self-help and screening, and targeted as well as population-wide health promotion activities.

Population health planning and evidence based needs assessments to be undertaken through Medicare Locals and Local Hospital Networks will help identify important population within their local communities. The Commonwealth and States will work together to identify ways to better target assistance to individuals within these different groups.

This will support selection by clinicians – general practices, community health, hospitals, etc. – of those who would benefit from these different levels of intervention and support, as well as self-selection by consumers experiencing difficulty in managing their condition or conditions. Top of page

1.3 Improve access for people who experience difficulty accessing primary health care, including Aboriginal and Torres Strait Islander people, people living in rural and remote areas, people with additional or specialised health care needs such as the elderly, people with disability, migrants or refugees and people with lower socio-economic status.

It is recognised that certain population groups in Australia will experience poorer health outcomes than the majority of the population.

A range of existing initiatives are in place that aim to reduce service gaps and improve health outcomes for these groups. Key examples include the Closing the Gap initiatives, a range of targeted mental health early intervention and suicide prevention programs, and the National Strategic Framework for Rural and Remote Health. However, it is important to recognise that there is still more to be done.

This action will require further collaborative effort between the Commonwealth and States, both in the health sector and across portfolios, and including Local Hospital Networks and Medicare Locals, primary health care providers, and consumers and higher risk population groups. Top of page

1.4 Recognising the importance of a child’s formative years – including the health and wellbeing of their parents, care during pregnancy, and early childhood development – develop integrated packages of services and support that maximise the opportunity for lifelong health and wellbeing.

Primary health care plays a crucial role in establishing the foundation for good health in the early childhood years.

While key aspects of ante and post natal care and preventative health care are provided through general practices, including health checks and immunisations, a range of other early childhood services contribute to improved early childhood health, for example, home visiting, parent education and breast feeding support. Schools also have a valuable role in teaching young children about their health and establishing healthier lifestyle habits.

Emerging issues, such as Foetal Alcohol Spectrum Disorder, highlight the need for coordinated action across a number of sectors. This action seeks to promote better integration of education, housing and social services in order to support healthier children and address gaps at the community level, including services for disadvantaged populations. Top of page

1.5 Medicare Locals will work with consumers, communities, health service providers and others to examine innovative care coordination and/or case management arrangements for people with complex chronic conditions, which focus on secondary and tertiary prevention, improving health outcomes and literacy, and reducing avoidable hospitalisations.

The National Primary Health Care Strategy identified that many patients, particularly those with complex needs, have been left to navigate the complex health system on their own. Even when supported by their GP or community health service, they have been affected by gaps in information flows and a limited ability to influence care decisions in other services. This has resulted in a small percentage of the population, who suffer from chronic complex conditions, accounting for a large percentage of avoidable hospitalisations.

The Commonwealth and States will identify possible models of multidisciplinary team care coordination and/or case management that will keep people healthy and reduce avoidable hospitalisations. Caring for people with chronic complex conditions at home or in the community will not only result in better health outcomes for individuals, but also reduce the pressure on the acute hospital system and on the community more broadly.

Examples of successful coordinated care include the Coordinated Veterans Care Program, as well as the Closing the Gap initiatives that deliver care coordination and support services through Aboriginal Medical Services. Other successful examples of coordinated care are also in place in some Medicare Locals.

This action will also support meeting the performance targets identified under the National Healthcare Agreement to improve the provision of primary health care services and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions.13 Top of page

1.6 Promote the role of consumers as partners in the health care team and empower them to make decisions about their own health and social needs.

Consumers have a right to make decisions about their own health care. When consumers are involved in decision-making, it results in better health outcomes, improved satisfaction, and greater ability in providing self-care.

Where practical, health system planning and design should evolve from a consumer perspective, with services being wrapped around the needs of the consumer, rather than consumers being required to adapt to the desires of policy makers, planners and providers.

Consumers need to be supported and encouraged to be partners in the health care team and be enabled to participate in decision-making about their assessment and treatment. This includes enhancing knowledge, improving decision-making, particularly in relation to consumer preferences and social or other lifestyle factors, and increasing consumer confidence in undertaking self-care.

This will require a change in the attitude and culture for many providers across the health system. However, it is an important shift that should be supported by all stakeholders. Top of page

1.7 Develop and promote innovative ‘pathways through care’ models which support more integrated and seamless care for consumers.

To improve health care for consumers it is important that consumers can, as much as possible, seamlessly move through the health system without being impeded by unintended barriers such as siloed delivery and funding structures. Commonwealth and State governments will support and build on demonstrated models that can provide ‘pathways through care’ that cut through these barriers to deliver a more seamless consumer experience.

Governments also aim to encourage ‘bottom up’ models of care. These models realise value for the consumer and can provide opportunities to be replicated and scaled accordingly. This will require clinical leadership and engagement to ensure collaboration and build partnerships across the care continuum. The increased use of the Personally Controlled Electronic Health Record (PCEHR) will also feed into this area.

This action can naturally extend in scope to include increased collaborations across allied health and other sectors through improved data collection and information sharing. Top of page

1.8 Manage more complex, urgent cases within the community by facilitating the development of integrated and ambulatory urgent care services in areas of need.

Throughout Australia, a range of general practices and other primary health care services (e.g. Aboriginal Community Controlled Health Services) have developed the competence and capacity to manage complex, urgent cases. However, in many areas a gap remains between the level of care currently available within the community and what care could be provided in the community; for example, hospitalisations could be avoided where there is capacity for more acute and urgent care to be provided in the home or in walk-in or ambulatory centres, or coordinated through care coordination and case management. Reorientation of service provision to the community setting can be increased with the support of Telehealth and Telemedicine.

Governments will build on existing services and identify best-practice approaches to improve access to integrated care services within the community. This will also facilitate better linkages between the primary health care sector and specialists to build additional capacity in non-hospital settings.


13 SCRGSP (Steering Committee for the Review of Government Service Provision) 2009, National Agreement performance information 2008-09: National Healthcare Agreement, Productivity Commission, Canberra