In part three of a series analysing the Government’s plans for the new primary health care organisations to be known as Medicare Locals, a range of Croakey contributors share their views.

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MLs must look for partnerships beyond health sector

Dr Tony Hobbs writes:

The four key priority areas for Australia’s first National Primary Health Care Strategy are:

1. Improving access and reducing inequity.

2. Better management of Chronic  conditions.

3. Increasing the focus on Prevention.

4. Improving quality, safety, performance & accountability.

The first of the five key building blocks in the Federal  Government’s response to these challenges is Regional integration – based on the establishment of Primary Health Care Organisations – “Medicare Locals”. The other building blocks include Information Communication Technology, Infrastructure, Skilled Workforce & Finance & System Performance.

For Medicare Locals to have a significant impact on achieving any of these four priority areas, they will need to facilitate improvements at the service delivery level with an emphasis on organised, well-connected multidisciplinary teams of providers supporting patients and their carers/families to better manage their chronic conditions.

Moreover, there will need to be greater community involvement at governance & service delivery level. Strong partnerships with local councils, the Aboriginal community, NGOs, housing & education will be essential if the social determinants of health are to be affected in a positive manner.

Previous commentary on Croakey has already highlighted these challenges: both for  organisations seeking to establish Medicare Locals against the criteria recently released by the Federal Government & for the government itself as it funds & prioritises programmes to be implemented by them.

Implicit in this regard is the need for flexibility in funding for Medicare Locals to be able to respond to the identified needs of their local populations, plan & deliver services in response & measure improved health outcomes.

Medicare Locals will not deliver the desired improvements in the above four key priority areas unless they have the capacity for population level planning & service delivery, flexibility in funding arrangements, strong partnerships with non-health sector groups and their local communities, and transparency in reporting their progress to their local community partners & their funders.

• Dr Tony Hobbs is a rural GP obstetrician who chaired the external Reference Group developing Australia’s first National Primary Health Care Strategy

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A reality check

Professor Stephen Leeder writes:

A general practitioner friend defined a Medicare Local as a pub with no beer. This devastating quip cuts to the chase as to what Medicare Locals will actually do.

Philip Davies has raised serious concerns in his detailed critique of the most recent round of information about them. More information is needed to address his concerns and those of other who ask what Medicare Locals are actually going to do. Melissa Sweet has asked why social determinants of health do not feature more strongly as a starting point for their development.

My guess is that we will need to see several Locals established to test the limits of feasibility.  One of the trickiest elements in the proposals for Medicare Locals is that they relate closely with local hospitals in achieving more integrated care for patients with chronic problems.  No-one should underestimate the complex micropolitics of achieving such arrangements.

Also, it is not as though no such arrangements exist already and we would be foolish not to analyse critically what has worked and what hasn’t in integrated hospital-community aged care and outreach programs for people with diabetes, heart failure, mental health, terminal illness and other long-term disabilities.

The financial arrangements between hospitals and Medicare Locals might follow the English pathway with increasing financial authority vested in general practice or follow an entirely different model.  The relations among Medicare Locals and existing corporate general practices will need careful negotiation.  So there is a lot to do as we move to a more community-responsive mode of health service, both in hospitals and in primary care.

Melissa’s disappointment about Medicare Locals not addressing social determinants might resonate with recent proposals in England for a reformed approach to public health that is highly localised.  There are documents to be read on this topic.  However, as I wrote recently about the English proposals in Australian Doctor:

Now, here’s the rub.  Yes, there are things we can all do locally to improve the health of the less privileged.  When done through local volunteering and citizens helping one another, however, much remains undone.  For instance, while much preventive clinical work is done in general practice in Australia, broad scale primary preventive efforts likely to change the environment favourably need central government leadership and clout – like dealing with tobacco advertising and other public health successes.

It is an unfortunate, ineradicable fact that unless there is central leadership together with national law and national policy the public health agenda is not fully achieved.  You cannot run public health unless you have troops stationed both locally and centrally.

We can palliate locally, and substantially assist to achieve public health goals, say through an enlightened local government that works closely with non-government organisations and the private sector. But central strength is needed to maintain a healthy economy, ensure larger-than-local vigilance against epidemics, secure safe water and clean air, change urban design in favour of better health, reduce the salt and trans fat levels in processed food, ensure early childhood is taken as seriously as it deserves as a health agenda-setting interval in life, and more on which public health depends.

Medicare Locals will likely elevate primary care in Australia and that is in my opinion a really good thing.  But we need to be careful to realise that they will not do everything.

• Stephen Leeder is Professor of Public Health and Director, Menzies Centre for Health Policy, University of Sydney, and Chair of the Western Sydney Local Health Network Governing Council.

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The future looks challenging, but hopeful

Mr Gordon Gregory and Dr Jenny May from the National Rural Health Alliance write:

On Wednesday of last week representatives of the 31 member bodies of the Alliance met in Parliament House with Minister Nicola Roxon, Rob Oakeshott and Tony Windsor’s policy adviser.  The purpose of the meeting was to hear a report from Minister Roxon to the rural independents on the health elements of the formal Agreement they have signed with the Gillard Government.

A number of topics were discussed, but considerable time was spent on the prospect for Medicare Locals in regional and remote areas.  The Alliance has been arguing for smaller (ie really local) Medicare Locals to be established, based on communities of interest and crossing jurisdictional borders where necessary.  It has also been arguing strongly that MLs must be better funded in regional and remote areas in order to meet the expectations of them – including their population health work to establish priority health needs and then moving to meet them.

The guidelines for Medicare Locals released this week and the comments of Minister Roxon are encouraging in several respects.  The funding of MLs will not be uniform but rather will reflect social and economic status, rurality and the proportion of Indigenous population.  The Minister agreed that they would be involved in workforce activity; this will be a major challenge.  The government sees Medicare Locals as the vehicle through which further reforms will be delivered, constituting “a fundamental shift in the centre of gravity from hospitals to primary care”.

It’s not clear what has precipitated the need for the quick review of proposed ML boundaries but the Alliance sees this as an opportunity to agree that there will be smaller ones or, at least, branch structures in Western Australia and South Australia, for instance, where huge Medicare Locals are proposed.

The Minister emphasised that, to succeed, they will need strong leaders.  The government aspires to them being fundholders eventually.

The Alliance is concerned to know how MLs will be able to integrate and measure primary care access and performance when the funding is still going to come from the States and the Commonwealth – ie in the situation in which (regrettably) the Commonwealth is now not going to assume funding and policy responsibility for all primary care.  This will certainly increase the level of complexity of the challenge confronting MLs.

With so many expectations of health reform now pinned to Medicare Locals, patience will obviously be required.  But it was encouraging to hear the Minister say that, eventually, Medicare Locals will be empowered to respond to the particular unmet health needs of their local area.

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And so the fragementation and inequity continue

Associate Professor Gawaine Powell Davies writes:

The new arrangements for Medicare Locals continue to unwind the potential for achieving a more unified health system. Private hospitals and specialists were already excluded from the reforms, and the separation between Medicare Locals and Local Health Networks maintained the split between primary health and acute care. The retreat from 100% Commonwealth funding for primary health care means that the split between general practice and community health will also continue.

One consequence of this is if the Commonwealth continues to develop primary health care through the private sector, largely on a fee for service basis, we can expect growing problems of equity, with services more available in areas where private practitioners wish to work and an increasing burden of out of pocket costs where gap payments arise.

Another is that community health is likely to languish, with pressure from Local Health/Hospital Networks to address hospital demand at the expense of broader primary health care work.

This is not to say that these problems cannot be addressed in specific instances, and the suggestion that Medicare Locals may move beyond specific program to more flexible funding is constructive here; but it entrenches an unconstructive set of drivers for the provision of primary health care.

More Medicare Locals and faster development are not necessarily a good thing: it is probably impossible to combine genuine localism with an efficient size and relationships with the LHNs without some smaller scale internal structure; and over-ambitious deadlines may force the pace of what are quite sensitive changes.

• Gawaine Powell Davies is CEO of the University of NSW Research Centre for Primary Health Care and Equity

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Primary health care reform must address needs of Aboriginal and Torres Strait Islander people

Selwyn Button, CEO of the Queensland Aboriginal and Islander Health Council, writes:

The recent release of expression of interest documentation to establish the new Medicare Locals Nationally presents some unique challenges for government, current Divisions of General Practice, the community controlled health sector and the broader community.

Given the level of detail on some aspects of these new entities and somewhat limited detail on other things, it is hard to determine whether new organisations are being established as improvements to the primary health care system or new arms of bureaucracy merely driving the government’s agenda.

This is particularly relevant given that new Medicare Locals are limited in their ability to brand themselves separately from government, as there will be common protocols relating to media, communications and marketing and reflected in ongoing funding agreements to remind the Australian public as to which government of the day actually implemented the reform.  Doesn’t sound too ‘Local’ at all.

There have been some gains made with the hearts and minds of government officials in relation to the inclusion of the words ‘Aboriginal and Torres Strait Islander  people’ and Aboriginal Medical Services in recent publications as this has been missing for some time. The common theme that ‘Closing the Gap’ will support the Aboriginal and Torres Strait Islander community reveals a lack of recognition that health reforms may represent the only opportunity to reform a broken system to improve the health needs of the sickest population of people in the country.

Which further leads to the exclusion of issues relating to addressing the inequities that exist in the current system supporting those most in need, and attempting to realign or redesign a system to ensure that all people in the community can access good quality care when they need from whomever can provide it in a timely manner.

A real life example of where this can work exists in South East Qld, through the establishment of the Institute for Urban Indigenous Health, which acts as a conduit for service planning and development, workforce planning and support and service integration across the community controlled sector, private practice and government services including hospitals to support streamlining the patient journey and continuum of care for Aboriginal and Torres Strait Islander people.

The Institute does, however, take a much broader focus to ensure that the social determinants of health are part of its scope as well, with strong connections to legal, housing, child safety and other relevant social services for appropriate referrals and continued support.

The community controlled sector believes that it is through establishing these models across the country that will ultimately support our people’s engagement in the health sector and ensure quality of care for improved outcomes, whilst new entities of Local Hospital Networks and Medicare Locals get themselves established and sort out how to separate themselves from government to become truly local to meet the needs of their local community.

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Fund-holding role will be vital

Professor Mark Harris, Executive Director of the UNSW Centre for Primary Health Care and Equity, writes:

The Commonwealth has set out an ambitious agenda for Medicare Locals which is significantly more than currently carried out by Divisions.

Perhaps the most challenging will be undertaking local health planning to identify gaps in services at the local level and better targeting of services.

This implies both a significant needs assessment and planning capacity which Divisions will need to have or “buy in”.  This has the potential to duplicate existing population health and planning units.  Surely it would be most effective for this to be facilitated in collaboration with local health networks or state public health services which currently have responsibility for this sort of planning.

Medicare Locals have the “potential” to administer “flexible funding pools to target gaps in primary health care service provision”.  It is unclear why there is only a “potential” for this.

This is a critical role for Medicare Locals if they are to develop coherent plans to  address equity gaps in of access to health care services in response to their needs assessment.

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Diagnosing the risks ahead

Andrew Podger, Professor of Public Policy at ANU, writes:

DOHA’s latest guidelines are mostly helpful, if within the still confused framework of reform Gillard and COAG have now settled upon.

The stated objectives of these organisations include the central roles of identifying health needs and developing responsive services, and facilitating successful primary healthcare initiatives and programs.

The guidance leaves room for variations in ML structures including within-region arrangements. It sensibly dampens expectations raised by the PM’s offer to increase the number of regions and to change boundaries, hopefully ensuring that ML boundaries align with LHN arrangements.

That said, it is not clear how MLs are to fit in the new health framework as a whole. They seem to have both planning (with some limited purchasing) responsibilities and some provider role. The former role has always been constrained by the insistence on MLs being independent companies, but in the longer term planning and purchasing should be their main contribution to the system.

The guidelines have endlessly repeated references to MLs’ role in ‘primary healthcare’, sadly reinforcing their limited influence over hospital services, leaving the strong impression that it will be the States (and to a lesser extent the Commonwealth presumably through DOHA) that will handle broader health services planning and purchasing.

There are other risks in the MLs implementation process that no doubt the department understands well.

These include the very ambitious timetable, the extensive performance and reporting requirements which appear a little unreasonable for the early stages of these organisations’ existence and the limits on the use of funds, particularly for the continued or transitional role of existing divisions as the MLs develop. Some leeway on these matters may well be needed.

I am not sure Gillard fully appreciates that the health reforms need the support of providers who pride themselves on their professional independence and want to contribute but not be directed.

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There are many reasons for skepticism

Dr Peter Davoren, President, Doctors Reform Society, writes:

We are very skeptical that they will have any ability to deliver what is claimed.

Primary Care is run by lots of small businesses and the ability of an underfunded government appointed agency to produce such wonderful results is doubtful.

Further there is no indication that MLs will have any power when it comes to negotiating with local hospital networks.

They really seem to be Divisions of general practice by another name.

As to equity, one of the main factors in helping to even out access to healthcare is adequate funding where it is needed. That should mean that Mls in regional and remote areas need more funds than those in the cities.

That is not indicated and it is unlikely they will be funded anywhere to have a meaningful impact on primary care.

Many of the social determinants of health are probably bigger than can be dealt with by MLs eg unemployment, lack of education.

Nevertheless the ability of MLs to provide housing for those with mental illness, transport and short stay accommodation for those who have to travel long distances for health care and access to healthcare services without charge would be important things such an organization should be able to do with adequate funds.

We would suggest that MLs should be able to amongst other things:

• Employ allied health staff so GPs have adequate access to allied health services
• Provide practices nurses to general practices (although the recent funding form the government may address this
• Be able to provide primary health care services with the assistance of nurse practitioners 24 hours a day, i.e. they should be able to employ such staff
• They should have legislated power to deal with local hospital networks to ensure their patients get adequate access to hospital care.

Finally, in regard to questions about MLs ability to make public comment, they should be able to make public comment and they should be answerable to the communities they serve. This is clearly a ploy by the government to cover their relatively useless initiative with smoke screens so at the next elections they can beat their chests and say they have done something about primary care.

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If you really want to address equity…

Dr Tim Woodruff (a Doctors Reform Society member commenting in a private capacity), writes:

1.      Social determinants: MLs can do little about these without information on population health needs and on current status of social determinants like housing, education etc. Government has promised to gather at least the former. But to do population health planning and address social determinants one also needs to know current expenditure on these ie health, housing, at a regional and subregional level, with particular reference to marginalised groups. There is nothing in the proposal which suggests this level of information, especially with regard to expenditure, will be made available. Much of it already exists but it’s all over the place eg in Medicare, local gov. state gov, aihw etc. Not collated. Medicare expenditure deliberately kept hidden by burearcracy and gov with secrecy agenda. Need Julian Assange! After getting the information , MLs do need to have the capacity to lobby and speak out about issues.

2.      Equity: as Peter Davoren said, we need a redistribution of funding to areas which currently miss out ie on basis of need. But data on current expenditure is kept hidden. (At state level, non gp primary  care services in Vic and NSW are funded on basis of need to some extent). This needs based regional level funding would go some way to addressing equity of access, but social determinants require more than just local needs based funding.

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Will they employ public health physicians?

Dr Yvonne Luxford, Chief Executive Officer, Palliative Care Australia, writes:

I applaud the Government’s commitment to enhancing primary care delivery, and I certainly hope that the intention of the health reforms to improve service integration and a seamless patient journey becomes a reality.

It is great to see that the MLs will play a prevention role within their communities, and I hope to see each ML engaging a public health physician to provide expert population health input. There also needs to be clear mechanisms to link the MLs with the new Preventive Health Agency on a number of levels.

The linkage with aged care is an important one that was missed in the earlier Discussion Paper, but it continues to be disappointing that there is no explicit mention of palliative and end of life care in the role of MLs. Medicare Locals have the opportunity to impact on system level integration of care for those with palliative care needs. However, significant support, education and development will be required to enable this. Levels of understanding of palliative care vary substantially amongst primary health professionals. This variation must be recognised and addressed through realistic levels of funding to achieve the necessary outcomes.

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Beware false promises

Associate Professor Geoff Couser, Associate Professor of Emergency Medicine, University of Tasmania, writes:

Whilst the proposal for Medicare Locals has admirable goals and looks good on paper (it’s hard to argue against preventive medicine and improved community based care, right?), much of the concept is based upon unsustainable models and false premises.

Nearly $500 million dollars is allocated for setting them up with nearly $200 million dollars per year for recurrent funding – without any real change in role delineation in the workforce or change in the complex relationships between community and public or private hospitals.

It could be argued that the existing primary care workforce carries out the same roles right now without a need for introducing a new system to achieve similar outcomes. Where’s the “new paradigm”?

Much of the rationale for the creation of Medicare Locals is based around taking pressure of emergency departments, but it is doubtful that such a result will occur unless other systemic issues are dealt with first (1). 1. Buckley DJ, Curtis PW, McGirr JG. The effect of a general practice afterhours clinic on emergency department presentations: a regression time series analysis. Med J Aust 2010; 192: 448-451.

Meanwhile, health costs are rising at a well-described and unsustainable rate, the same workforce pressures will exist and will ultimately fail to meet the needs of the community, and no real reform will actually take place. We’ll be left with an expensive illusion and more crises in the health system that we won’t be able to afford to fix when they rear their heads again in a few years’ time.

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Clarity is needed around their population health roles

Public Health specialist Associate Professor Peter Sainsbury writes:

·        Re the MLs’ responsibilities for the health of the local population, which previously seemed to indicate that they would have a general responsibility in this regard, similar to what Area Health Services in NSW had and perhaps causing confusion with what the new Clinical Support Clusters seem like having, that seems to have been scaled back a bit now to identifying and focusing on needs that are relevant to clients/patients rather than the pop of a geographic area. I may be wrong but that was my reading of it. If I’m correct, I think it’s a good move to avoid confusion and also because I’m sceptical that most MLs will have the skills to do the broader job, certainly not in the short term.

If I’m wrong and MLs will have a general responsibility for the health of their geographic population I think (a) there will need to be strong coordination with whichever structures in each state have responsibility for public/population health/health promotion, and (b) this task will need to be undertaken by the MLs themselves, not by individual GP or primary health care practices – see comment below.

·        While I think MLs, GPs, primary health care practitioners, etc. do need to be aware of the social determinants of health and equity issues insofar as they should influence the services they provide to/for clients/patients in general and the way they manage individual patients, I have always been a doubter when it comes to GPs and other primary health care workers being ‘forced’ to take too much general responsibility in this regard – ie beyond patient care. Reasons: generally speaking they aren’t terribly interested in these issues, they are interested in treating sick people; generally speaking they are not trained in these issues or what to do about them; generally speaking they aren’t resourced to deal with these issues; and most important of all, the priorities, to my mind, for primary health care over the next decade should be firmly focused on improving the quality of care (see next point) provided in primary health care and the integration of primary health care with secondary and specialist health service providers and other social service providers in the community – ie they should be doing their core business a lot better rather than branching out into other areas.

·        Re ‘care’ – I am principally referring here to the management of acute and chronic illness and life conditions (eg pregnancy and early childhood) – ie the core business of primary health care providers in my opinion – but I do agree that they do have a role implementing evidence based ‘health promotion’ interventions with their patients.

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For more media coverage of Medicare Locals:

• We will need more money, says Australian General Practice Network

• The AGPN at Medical Observer

• One division’s response

• The Royal Australasian College of Physicians

• Keep GPs central, insists AMA

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For previous related Croakey posts:

• How will Medicare Locals work?

• We need a broader focus, and stronger commitment to consumer/multidisciplinary involvement

• Philip Davies: some challenges ahead