Primary health care in an ageing society

Welcome to this edition of the Australian Journal of Primary Health on primary health care in an ageing society.

In putting this Special Issue together, we called for papers that explored the intersection of primary health care and the health and well-being of older people. We were interested in research, practice and theory that considered how to meet the challenges of supporting people to maintain active and healthy lives in their own homes in their community for as long as they want to. We recognised that more and better integrated primary and community services are seen as part of the solution to achieving more effective and efficient care for the health and well-being of older people.

The intersection of primary care and aged care becomes more important as the population ages and more older people with complex needs continue to live in the community, including at the end of their lives. It is interesting to see how many papers in this Special Issue consider the challenges associated with the way primary care – particularly general practice and allied health care – and aged care services intersect. Primary care and aged care sail in the same ocean. Sometimes the two ships miss each other, sometimes they collide, often they just see one another’s lights in the dark in the distance. Older people travel on both, of course, and it would be better if primary care and aged care were better integrated and focused on linking to produce the best outcomes and experiences possible.

Life expectancy has increased dramatically (Lopez and Adair 2019). Many more people are living into their 80s and 90s. Population ageing has many benefits, but it also produces new challenges. Chronic conditions, including cancer, cardiovascular disease, neurological conditions and musculoskeletal conditions, are now the most significant burden on the health system and the main reasons people need long-term care (Australian Institute of Health and Welfare 2021). Temple et al. (2021a) explore support needs and well-being of those caring for older Australians using national data, and highlight risks associated with unmet needs. Kong et al. (2021) explore how older adults manage chronic diseases by themselves, and how this is affected by their general activity ability level.

Governments are under pressure to provide high-quality, accessible long-term care services in the community. Few older people want to live in residential care (Roy Morgan 2020) when they become frail and, not surprisingly, a rapid expansion of home and community care is under way. Already approximately 1 million older people are supported to live in the community and the Commonwealth is dramatically increasing the number of older people with complex needs that it will support in the community over the next 3 years. Mann et al.’s (2021) paper underlines how important it is to recognise that complexity includes multi-morbidity, but also cultural context, living and caring circumstances. Waller et al. (2021) look at the prevalence of frailty among older adults receiving home care packages and argue for the importance of early detection and intervention. Mitchell and D’Amore (2021) look at state and national trends in uptake of the Medicare Benefits Schedule (MBS) items for health assessments of older Australians, which were introduced in 1999 to support comprehensive needs assessment and appropriate responses. Ramisetty et al. (2021) explore attitudes of GPs and PNs to older person health assessments to explore why there is still generally low uptake.

There are significant concerns about the access, quality and cost of both health and aged care services for older people. These have been extensively documented (Royal Commission into Quality and Safety in Aged Care 2021). For example: dental services are expensive and often not available in rural settings; older people often have difficulty traveling to health care in regional centres; it is often hard to get health care at home for complex conditions like dementia and end of life care; and allied health services are hard to get delivered at home and in residential care settings (although new MBS item numbers for physiotherapy services delivered in residential aged care facilities were announced in early 2021). Several papers in this issue (Kunin et al. 2021; Temple et al. 2021b) consider the barriers faced by older people and their carers trying to find primary medical care. Yates et al. (2021) look at the characteristics and experiences of ‘grey nomads’ travelling across Australia and highlight a lack of information required to support regional and rural service planning and provision of healthcare services.

What would well integrated primary and community aged care look like? Services would be personalised and tailored to provide social and health care at home to assist people to live the way they want to in the community with their family, friends and acquaintances. Services would be controlled and responsive to users, thereby respecting users’ rights and choices. They would include extended hours medical, nursing and allied health care and rapid support to manage acute episodes at home, and home-based palliative care. They would be integrated with home-based personal and social care and daily social programs. In this issue, Quigley et al. (2021) report on an innovative model that aims to provide better integrated care for older people with complex needs by co-locating specialist geriatric services and enablement-focused nurse or allied health professionals working with GPs in a primary care setting.

In practice, aged care and primary care have different policy frameworks, funding and governance arrangements, and they are very differently organised. Primary care, particularly general practice and allied health is generally delivered by large numbers of small, siloed professional practices operating independently of one another funded through uncapped fee for service. Governance is light touch. Home visiting and after-hours care is in short supply and intensive home-based rehabilitation and post-operative care is generally provided by hospital outreach programs. Aged care is dominated by much larger organisations and budget capped funding administered through provider contracts. It has highly centralised, transactional, regulatory and governance structures. Nursing and allied health care are provided through these contracts, but medicine, dentistry and pharmacy are brought in from the private sector.

There are few funding, governance or coordination mechanisms in place to enable the range of services that might be required to work together effectively. More integrated services need to be encouraged and supported by reformed funding, governance and accountability arrangements. Arguably a much broader reform agenda to improve primary health care services for older people is needed. This special edition sets some pointers for issues that should be taken up.

The authors declare no conflicts of interest.