This paper proposes a sustainable model of General Practice and primary health care at a time of significant primary health care reform and change. Within the context of the creation of Primary Health Networks (PHNs), the release of the National Review of Mental Health Programmes and Services report and the Reform of the Federation, and the establishment of Medicare Benefits Schedule (MBS) Review Taskforce and the Primary Health Care Advisory Group (PHCAG), this model will help ensure optimal future outcomes for patients with chronic conditions and complex care needs. The model aims to embed the concept of a Patient-Centred Medical Home (PCMH) within primary care that also incorporates a multimodal payment system for General Practice which aligns incentives with outcome-focused care.

To ensure the model is evidence-based, sustainable and scalable, the paper recommends a pilot programme which will focus, in particular, on testing the efficacy of the design of incentives to achieve the expected benefits.

To this end, the paper’s strength and novelty lies in analysing and addressing the practicalities of implementation.