Primary health care systems
This Guide provides information about and sources of further information on the primary health care systems in Australia, Canada, the United States, the United Kingdom, the Netherlands and New Zealand.
Australia has three levels of government: federal, state/territory, and local government and a complex PHC system with both public and private components.
The Australian Government introduced the Medicare system in 1984. All Australian Government funding for health services comes from taxation through its general revenue. A Medicare Levy is set at 1.5% of taxable earnings (for all but low income earners). A surcharge of an additional 1% is levied on high income earners who do not have private health insurance.
While general practices are private businesses, Medicare covers general practice consultations although in many cases a co‑payment is also charged by the practice. The Australian Government funds the Pharmaceutical Benefits Scheme (PBS) which substantially covers the cost of medications.
Private health care financing is from out-of-pocket payments and optional private health insurance. Unlike many countries, Australia has no employer-based health insurance schemes.
Operating across multiple jurisdictions is one of he biggest challenges for PHC in Australia. This is due to divided responsibility for health care between federal and state/territory governments, private and public systems, and community, hospital and long term care settings. Medicare, PBS and Medicare Locals are funded by the Australian Government and hospitals are jointly funded and managed by the states.
Since 2011 the Australian Federal Government has funded Primary Health Care Organisations, known as Medicare Locals. These are located regionally around Australia and work with general practitioners, practices, allied health and other PHC providers and the community to improve quality and access to the PHC sector, implement government programs and run diverse health projects. The Australian Medicare Local Alliance (AML Alliance) provided leadership, governance, representation and advocacy at a national level until it ceased operating on 30 June 2014. However recent reform suggests new Primary Health Networks will be established in 2015.
Both the Australian Government and individual states run health programs and initiatives which are implemented in primary care. In practice this can lead to duplication in bureaucracy, cost shifting and conflicting requirements. The GP workforce supply is a major issue in rural and remote areas and increasingly so in the urban fringes. As in other countries, increasing demand due to the changing demographics of the population, ageing of the population and the increasing need for services to manage chronic health conditions, are driving system reforms.
Canada’s publicly-funded health system provides universal access to hospital and medical care. In Canada, primary care responsibilities are divided between federal and provincial governments. The Federal Government is responsible for setting and administering national standards, financing the system through payments to the provinces, delivering care to First Nations, Inuit and veterans, and providing drug and food safety regulation, data collection and research. Provincial governments retain responsibility for the shape and administration of their health systems, guided by the Canada Health Act. This system has sufficient flexibility to allow different models of health care service delivery (including multidisciplinary team care, patient enrolment, capitation and blended payments), based on agreements between the Ministry of Health (federal level) and local health authorities (provincial level).
Most family physicians are remunerated on a fee-for-service basis paid by the national insurance system (Medicare), which is funded through taxation. There are some salaried GPs and in some areas there is a blended system of salary, capitation and fee-for-service in order to provide incentives for better preventive and chronic disease care. Primary health care is delivered at no charge to the patient. GPs receiving any funding from the public system cannot charge higher than the rate fixed for the specified service.
Primary Health Care Organisations to coordinate primary health care services have been established across multiple provinces in Canada (e.g., Alberta Health Services; Centres locaux de services communautaires in Quebec; Local Health and Integration Networks in Ontario).
The USA government is a federal system. Federal government power is defined and limited by the Constitution. The most significant health reform in the US was the passing of the Patient Protection and Affordable Care Act (PPACA) in 2010, often referred to as the Affordable Care Act.
The primary aim of the act is to improve access to appropriate health care by removing cost as a barrier. This Act includes broad changes to governmental programs which deliver medical and health related services (Medicare and Medicaid). Full implementation of the act occurred on January 1, 2014, when the individual and employer responsibility provisions took effect, state health insurance Exchanges began to operate, the Medicaid expansions took effect, and the individual and small-employer group subsidies began to flow.
The Act aims to achieve near-universal coverage through shared responsibility among government, individuals, and employers; to improve the fairness, quality, and affordability of health insurance coverage; to improve health care value, quality, and efficiency while reducing wasteful spending and making the health care system more accountable to a diverse patient population; to strengthen primary health care access while bringing about longer-term changes in the availability of primary and preventive health care; and finally to make strategic investments in the public's health, through both an expansion of clinical preventive care and community investments.
The act encourages the federal (Secretary of the U.S. Department of Health and Human Services) and state Medicaid programs to test new modes of payment and service delivery, such as medical homes, clinically integrated “accountable care organizations,” payments for episodes of care, and bundled payments. An Accountable Care Organization (ACO) is a model of configuring health care organisations by a payment and service delivery that links provider reimbursements to measures of quality service delivery and reductions in the total cost of care for an assigned population of patients. ACOs have substantial flexibility in terms of their organisational requirements, performance measures and payment models.
The UK health system, the National Health Service (NHS) is funded through taxation to provide free primary health care services to all UK permanent residents.
The English Department of Health takes responsibility for UK -wide issues but the UK has four quite separate health care systems across Scotland, Wales, Northern Ireland and England. Responsibility for health care has been devolved to each of the constituent countries which are adapting the NHS model for local preferences and circumstances.
The most recent policy implementation of the Health and Social Care Act 2012 saw the establishment of a variety of new bodies. Monitor is the sector regulator for health services in England. The role of this body is to protect and promote the interests of patients by ensuring that the whole sector works for their benefit. Clinical Commissioning Groups are groups of general practices working together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services including: planned and urgent/emergency hospital care, rehabilitation care, community health services and mental health and disability services. At a local level, Health and Wellbeing Boards were set up in Local Authorities to ensure that Clinical Commissioning Groups meet the needs of local people. Health and Wellbeing Boards bring together clinical commissioning groups and the local councils to understand the health, social and wellbeing needs of communities. The Act also implemented the establishment of Healthwatch to advocate for patients.
Rather than providing remuneration to individual practitioners, funding is provided at the practice level. The Clinical Commissioning Groups contract general practices, which are independent businesses, to provide services for NHS patients who are enrolled with the practice.
The Netherlands Ministry of Health, Welfare and Sport is responsible for the development of policies to ensure the health and social wellbeing of the residents in this small densely populated country. In 2006, a structural health care reform was implemented. The reform introduced a single compulsory insurance scheme, in which multiple private health insurers compete for insured persons. The Netherlands is similar to the United States in having a health system based on private providers with government responsibility for the accessibility, affordability and quality of health care. Health insurance is compulsory and the government contributes for those unable to pay.
The Health Insurance Act (Zorgverzekeringswet) has been in effect since January 1, 2006. The implementation of this act was part of a reform process planned to last to at least 2012. The main incentives used by health policy in the Netherlands are: introduction of market competition; enhancing the room for contracting between health insurers and provider agents; enhancing consumer choice; public reporting on hospital performance (hospital ranking).
General practices are private businesses which enter into a contract with insurers to supply services to the customers of the insurance company. GPs are paid a capitation fee per patient registered with their practice, a fee per consultation and a negotiable reimbursement for practice costs, depending on services offered, staff employed, and the achievement of quality and efficiency indicators. These fees are paid to the GPs by the insurance companies.
Most GPs are independently established and self-employed. Patients in The Netherlands choose their own family physician, but are required to register with a practice. Many practices employ a practice nurse to provide chronic disease management and, similar to the US physician assistants role, most GPs employ doctor's assistants who can perform simple medical procedures such as taking blood pressure, syringing ears, giving injections and performing vein punctures under instruction from GPs. Out-of-hours centres or cooperatives provide access to PHC services from GPs, nurses or doctor's assistants from 5pm to 8am.
The NZ parliament consists of one chamber, the House of Representatives. Local government has a two-tiered structure consisting of 12 regional councils and 73 territorial authorities.
Twenty one District Health Boards (DHBs) have responsibility for the provision of health and disability services within specific geographic boundaries.
Funded by the DHBs through capitation funding formulas, 36 Primary Health Organisations (PHOs) deliver and coordinate a team of health professionals (doctors, nurse practitioners, allied health and other professionals) to provide services for enrolled members of their communities and distribute funds to contracted GPs and other primary health care providers. Enrolment with a PHO is not compulsory but enrolled citizens can receive population health and preventive care through the PHO. A PHO provides services either directly or through its provider members. These services should improve and maintain the health of the entire enrolled PHO population, as well as providing services in the community to restore people’s health when they are unwell. PHOs vary widely in size and structure, although all are not-for-profit organisations. Capitation payments to GPs are administered through the PHO however GPs also have the option of charging patients a co-payment. The Ministry of Health reports on quarterly progress towards achieving agreed primary care health targets for each PHO. PHO league tables and summary results for each year are also reported.
The Better, Sooner, More Convenient Primary Health Care policy was launched in 2009 by the NZ Ministry of Health. Primary Health Organisations are one vehicle through which the NZ Government’s primary health care objectives were articulated. Pre-existing primary care organisations primarily represented general practice services, with limited engagement of other PHC and community providers. The policy encouraged existing PHOs to merge to improve their capacity and capability to manage change. At the core of this policy lies an integrated health care system that allows health care practitioners the freedom to devise strategies to meet the specific needs of their local community. The key strategies in this approach involve expanding roles via additional training, telehealth and eHealth, co-location of services and arrangements to support multidisciplinary teamwork.
Oliver-Baxter J, Brown L, Bywood P. (2013). Integrated care: What policies support and influence integration in health care in Australia? PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research & Information Service
Davis K, Schoen C, Stremikis. (2010) Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally: 2010 update
McClellan M, McKethan A N, Lewis J L, Roski J, Fisher E S. (2010). A National strategy to put accountable care into practice. Health Affairs 29(5): 982-990.
Rosenbaum S. (2009). Medicaid and national health care reform New England Journal of Medicine 361(21): 2009-2012.
European Observatory on Health Systems and Policies WHO Regional Office for Europe
Health Services and Delivery Research National Institute for Health Research
Health close to the people (2012) Netherlands Ministry of Health Welfare and Sport
Trust in the care- Policy objectives of the State Secretary for Health, Welfare and Sport (2011) Netherlands Ministry of Health Welfare and Sport
Data and Statistics New Zealand Ministry of Health
Primary Health Care Strategy New Zealand Ministry of Health
Sources for international comparison
Health Affairs The journal Health Affairs has published a series of multi country studies by Cathy Schoen and her colleagues.
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