Issue 39 / 14 October 2013

AUSTRALIA’S new federal government has a lot to do to improve population health and maintain Australia’s place as a high performing health care system.

Existing primary care services are fragmented and focused largely around general practice, hospital services are costly and overutilised, and the system fails to seriously focus on disease prevention and health promotion activity. There are also gaps and inequities in access to services and variations in health outcomes between different population groups.

The system is often criticised for being provider-centric rather than patient-focused.

There have also been some whisperings around the fate of Medicare Locals under a Coalition government.

The establishment of Medicare Locals was a fundamental element of the previous federal government’s national health reforms.

The key principle underlying the Medicare Local reform is that local agencies are able to interact and network more easily with local communities and are thus better placed to interpret and understand the needs of these communities, while also having the potential to be more open and transparent in the delivery of public policy.

However, when in opposition the Coalition criticised them as wasteful bureaucracies.

With many Medicare Locals only just celebrating their first anniversary it is too early to have strong evidence on their success or failure. Reform and change takes time. A strong message from the literature is not to change for change’s sake — a trap that many governments across the world seem to fall into.

Medicare Locals have, so far, managed to undertake a population approach to needs assessment, providing detailed information on the health needs of the populations they serve. They have also started to map local need against the supply of health services, identifying gaps and inefficiencies in service provision.

A number are also using spatial information to inform planning — this approach can allow for focus on aspects around equity and the wider social determinants of health. This type of population planning and information generation can play an important role in the development of local health systems and over time this could allow for more integration and focus on aspects around efficiency, equity and quality.

Involvement of GPs is crucial to population planning, but it is not something that they have traditionally been able to undertake beyond their local practice area. Thus, Medicare Locals have a unique and key role in working with GPs and other health providers in shaping and coordinating primary care services.

This role is not easy, especially given the limited powerbase of Medicare Locals. Other countries grapple with similar issues and there have been a number of different technical solutions developed to help primary care population planners.

While such approaches can be helpful it seems it is the people and relationships that are a key ingredient to success. Medicare Locals will need leadership skills that can navigate the political complexities of working within and across organisations with differing incentives systems and cultures.

So what does the government need to consider if we are to tackle some of these issues? Policy needs to focus on system reform and value, recognising that patients’ needs are complex and the health system needs to reflect this with more integration between community and hospital services. If we are serious about equity then services need to be better directed around patient needs.

There is extensive evidence to demonstrate that strong primary care systems have been shown to improve health outcomes and cost effectiveness. When coordinated effectively they can also lead to more equitable service provision.

All political parties seem to agree that the country needs to use resources wisely and evidence would suggest that irrational structural change based on political need, rather than population, could prove very costly in both the long and short term.

It’s important to give Medicare Locals a chance and reflect on what has been achieved to date. Some change is probably needed, but more around the number of Medicare Locals and the support (both state and national) they are offered in their role, rather than developing new organisations — or worse, reverting to the old system.

A strong message to the new government would be that it is never a good idea to throw the baby out with the bath water.

 

Associate Professor Suzanne Robinson is director of Health Policy and Management, Faculty of Health Sciences at Curtin University.

23 thoughts on “Suzanne Robinson: Healthy change

  1. Susan Dickinson says:

    What is happening about Divisions of General practice? Where do they fit in with medicare locals.

    How does this help general practice and patients? is all just political paper shuffling?

    Is it making GP’s lives even more difficult in trying to look after their patients properly. In all of this in medicine the patient must come first – policiticans and bureaucrats unfortunately don’t support this model

    Retired GP

  2. DR. AHAD KHAN says:

    There are 2 major Issues with Medicare Locals –

    1. Whilst the previous Divisions of General Practice, had the GP in the Pivotal Lynchpin Position, around whom all Allied Health Care Providers revolved, the Medicare Locals fails to recognise the GP as the pivotal Lynchpin, around whom all Allied Health Care Providers must work.

    2. Whereas the constitution of the Board of Divisions of General Practice was made predominantly of GPs, I gather there is a stipulation that the Board of MLs cannot have >50% of its Members as GPs. The Voice of the GP must not become a Voice in the wilderness.

    Unless these 2 major Issues are immediately corrected, I would strongly advocate for bringing back the Divisions of General Practice & dismantling  the MLs altogether.

    DR. AHAD KHAN – GP

     

  3. taylorr@amamember says:

    If the bureaucracy likes and promotes a programme it is likely to be either for political kudos to suit the party in power, or for cost control and other forms of control like control of medical care policy on PSA testing for example. So, I favour scrapping anything the bureaucracy promotes.

  4. Dr Malcolm Brown says:

    I agree with Dr Khan – the central role of GPs in primary care has been a key reason why health standards in Australia are so high. Adequate health service planning can be done at State level, so the role of Medicare Locals remains unclear.

  5. DR. AHAD KHAN says:

    There is extensive evidence to demonstrate that strong primary care systems have been shown to improve health outcomes and cost effectiveness. When coordinated effectively they can also lead to more equitable service provision.” – so you state, Suzanne Robinson. But, today, Australia’s Primary Health Care is the envy of other Nations – it is in a very healthy state as it is Suzanne. You will do well to remember – ‘ Do not repair, if it ain’t broken ‘. Measures to further strengthen the arm of the GP is what is needed.

    You also state this – ” A strong message from the literature is not to change for change’s sake — a trap that many governments across the world seem to fall into.”  Hence,  replacing Divisions of General Practice by Medicare Locals does not make sense, except to dismantle the GP from the Pivotal Lynchpin Position, around whom all Allied Health Professionals ought to revolve.

  6. Dr Judith O'Malley-Ford says:

    The Divisions of General Practice served a function “of sorts”, but I am yet to determine the function of the Medical Locals. They receive large allocations of funding , and for what.

    General Practice can no longer be called be called “general” in the real sense of the word. GPs are specialising in a single form of service provision in order to maximise the ever dwindling income from general practice. Once upon a time, the GP was the co-ordinator of primary health services for patients. That is no longer the case. A typical general practice now deals with the issues of the chronically ill, infirmed, disabled, children all of whom constitute bulk billing patients. And the Medicare Locals do not act as sources of value added service provision.

    General practitioners are struggling with the complexity of  patient load as never before. E-health will only make this worse.  It’s time that the service that GPs provide is recognised for what it is, and remunerated accordingly. The $$ that are invested into Medicare Locals should be diverted to where the rubber hits the road… GPs

  7. iannuzzi@tpg.com.au says:

    Sadly, I have not seen any benefits to Medicare Locals anywhere so far. It appears to be a producer of more red tape, more distraction and more diversion of funds away from the GPs and patients. The control of the organisations has sidelined GPs, or at best relegated them to minority status. Offices have been set up all over the place at great expense. Medicare Locals appear to be taking policy and directives from Canberra, state capitals and unversity departments; none of this is LOCAL! The whole thing is a big mess and best dismantled now before it gets further out of hand.

  8. Walter Kmet says:

    Thanks Suzanne for your thoughtful piece. Evidence shows that strong primary health care systems make a sustainable and effective contribution to better health outcomes and keeping people out of hospital. Systems need to evolve as the needs of our patients and community change.

    Unlike hospitals however we often lack the investment in primary care to take a system approach. More often than not patients feel that their journey through a complex health system could be better coordinated and many patients, particularly those who are socially disadvantaged, miss out. For these patents the system we have come to rely on doesn’t meet their needs. GPs need more support so they can have an effective, central and ongoing role in patient care. For many GPs balancing day to day practice responsibilities with this objective is singularly impossible.

    The introduction of Medicare Locals have for the first time meant that a system approach is being taken. This is an avenue to better support GPs and their practices. This support should be locally or regionally based because that’s where most services are provided. Centralisation removes control from local GPs and hospitals, limiting their ability to plan together and make decisions about their own needs, many of which vary across states. Health Pathways, diabetes planning and Practice Capacity Grants in western Sydney are good examples of local solutions that strengthen General Practice.

    Medicare Locals are at various stages development but the momentum is significant. Examples of effective local solutions to new and some old challenges are equally apparent. As you say this is not the time to throw the baby out with the bath water.

  9. Glenn Rosendahl says:

    Suzanne Robinson, you do not have a medical degree, you are a career academic, and have only in the last 12 months come from the UK, where primary health care has been delivered on a ‘capitation basis’ for numbers of decades. This model has very little favour in Australia.  

    One of the first tasks given to Medicare Locals was ‘after-hours care’.  The budget was transferred from contracted practices to Medicare Locals and they were directed, “arrange after-hours care in your area – on a bulk-billed basis”.  The money was less than previously provided, once the ML had taken out its administration fee.  Local doctors said to the ML: ‘You have the money, you provide the service’.  The ML responded, ‘We cannot provide the service, because we are not doctors in practice’.  The ML presented a simple ultimatum.  ‘You doctors provide a free service, for less money than was provided before.’

    Labor established power centres to increasingly control and direct general practice in ways – and toward goals – defined by its ideology.  Simplistic, motherhood concepts that in reality are utterly impractical.

    Please do not make motherhood statements about saving MLs.  If you have useful knowledge, present it as explicit policy recommendations about what MLs should be doing.

     

  10. Jo Sutherland says:

    I attended a meeting today between the LHD and Medicare Local, which dicussed ways of introducing Health Pathways, a process which aims to improve patient access to specialty and hospital-based services. The funding will be provided jointly by the 2 organisations, and local doctors are already involved.  I think this opportunity is a good example of how the Medicare Local and the health districts can work together in the interests of patients. In a complex and  fragmented system, it is encouraging to see an example of co-operation and collaboration, with the needs of patients driving outcomes.

  11. Alexander Chan says:

    My concern is the bureaucracy involved in referring mental health patients to the Local Medicare ATAPS. So many pages of information need to be filled that it would need an hour of consultation to collect all the information and then half an hour to fill in the forms. This actually stops a number of GPs I know and myself from referring patients to ATAPS run by the Medicare Local. Is this an advancement in improving access to Mental Health for the patients??

  12. Tom Reeve says:

    MLs will only work if the coordinators understand the problem, too many bureaucrats are undertrained &

    help their misunderstandings mislead  patients. A well trained GP could replace anumber of the “committed’ 

    like the non medically trained author of this article.

    Why not help the GPs more directly & effectively.

    Speak to people rather than fill in forms.- meaningful discussion between understang peple can be a 

    winner.

  13. Department of Health Victoria Clinicians Health Channel says:

    My experience with the MCL have been negative so far. It involves more money spent on administration and less money on the clinical services.  The services are already too fragmented as it is.  MCL or any other system that promotes further fragmentation is almost certainly results in more wastage. There has to be a leader in any team structure. I am not convinced that shifting the responsibilty from the GP or the medical profession will result in improvement in efficiency and less wastage of resources. It is almost certain that it will be the other way round.  Please note that I am not a GP and therefore not self promoting my own importance. The aim should be to minimise duplication and reduce bureaucracy and not to increase it which MCL will.

  14. Genevieve Freer says:

    Medicare Locals have no evidence of cost-effectiveness in health care delivery so should not be funded.

    Medicare Locals are an example of failed Labour Government big brother bureacratic  policy from capital cities, the musing of   hypocrits who enjoy the best of urban healthcare, while  we workers in rural areas struggle to help our  patients access  health services the urban  politicians , their families  and friends take for granted.

    Australia has ditched the failed government, so I suggest we dump  the failed policies , of which the after-hours farce run by bureaucrats in offices is a typical example and along with their IT , E-health , and demands for confidential patient information  reek of government control of the patient record,  raising patient  and practice confidentiality issues.

  15. Frances Boreland says:

    Interesting that some of the comments here raise the issue of GP funding. These pages from GP Australia (see links below) suggest the average GP in Australia is hardly doing it tough and earns much more than the average person, altough they do earn considerably less than specialist colleagues. More policy emphasis on maintaining wellness, reducing barriers to maintaining wellness (eg provision of adequate income to the unemployed) and better co-ordinating care might be helpful in improving health. If Medicare Locals are able to do that they are well worth supporting. http://www.gpaustralia.org.au/content/what-can-you-earn http://www.gpaustralia.org.au/content/news/average-gp-earns-182k-calculate-what-you-could-earn

  16. SUZANNE DALY says:

     If it ain’t broke don’t fix it! There is nothing wrong with primary care that more workforce at the coal face won’t fix. The  system that is broken is the hospital system. Spend the money there to increase PUBLIC HOSPITAL funding to do away with waiting lists. Again more money at the coalface and less spent in offices.  The original divisions were grass roots and we did come up with local solutions to local problems. These were gradually overlooked with more control from Canberra. It got ridiculous when we recieved more money for the few indigenous and could not get funding for any projects for the aged !!  The Medicare Locals have now done the population studies that support aged care as our local problem. Disband them now and give the money back to the original divisions. I doubt the Medicare Locals will be as efficient and I doubt they will come up with anything more worthwhile in the future. !!

  17. Nick Cooke says:

    As a previous Board member of a division I am very concerned about Medicare Locals. I feel they are spawned from Labor party ideology and not sound economic planning,  and, like so many of the previous governments ideas,  doomed to fail as they have failed to take into account what happens in the real world and how people really behave. Marx had the same problem.

    I have moved to a new practice and in a different Medicare local area yet in six months since I moved, I have received no contact  and been engaged in no meanngful way by the ML. I have no idea what my new ML offers or its plans for the future and neither do my colleagues in the practice. MLs have failed to engage the hearts and minds of GP and provide them with meaningful support. They are perceived as less relevant than divisions and divisions had almost no support before they morphed into MLs.

    It is all very well talking about allowing reforms to have time to show their worth. I totally agree that all too often, and especially in the UK , reforms are made and the agenda of the government that has to be seen to be doing something in health, ensures that changes are made. With Medicare Locals and the current  lack of engagement of grass root GPs and their complete disinterest, I am afraid that it is a “no brainer” to say that MLs have failed and will not provide a meaningful increase in the equitable access to quality healthcare. Sorry but that is the way it  is.

  18. Dr R.J.PHIPPS says:

    I HAVE WORKED FOR SOME MONTHS IN A MEDICARE LOCAL.

    THE PREMISES ARE WONDERFUL, FAR MORE THAN AN ORDINARY GROUP OF GPS COULD PROVIDE[ IT IS GOVERNMENT FUNDED] WITH VARIOUS ANCILLARY SERVICES, PSYCHOLOGY, PHYSIO, AUDIO, DIETITIENS,PATH,EXERCISE PHYSIO, EXERCISE PROGRAMS .

    ALL RATHER PIE IN THE SKY, AND RUNNING AT A LOSS, ONLY BULKBILLING, AND EXTERNALLY DIRECTED.

    ONLY A MINOR A CHANCE FOR GPS VOICES TO BE HEARD BY THE POWERS THAT BE AND NO REAL PERSONAL TOUCH BETWEEN.

    .MUST BE SUPPORTING AN EXTERNAL BEUROCRACY.

    WOULD BE GREAT IF THAT SORT OF FUNDING COULD BE MADE AVAILABLE TO ORDINARY GP PRACTICES AND THEN WE WOULD SEE SOME REAL PROGRESS AND BALANCED BOOKS.

  19. Dr. Rudy Lopes FRANZCOG says:

    I would suggest that MLs have failed in two key areas:  (1) enagagement of local GPs to own and participate in the provision of services; and (2) solving the problems of local medical service provision – they seem more involved in surveying the local situation, then surveying the surveys, effectively spinning wheels rather than providing any concrete solutions.

    I am of the opinion that improving primary health care and preventative medicine is the key to economic and cost effective provision of medical services – the idea should be to keep people OUT of expensive hospitals and in the community that is better able to care for them, particualrly given the aging population and the increase in people with chronic disease. Returning the responsibility of local medical service provision back to individual GPs and Divisions rather than a central, Canberra run bureaucracy would be my solution to the mess that MLs appear to represent. The role of an effective electronic health record system that by streamlining information transfer (currently done through cumbersome, time-intensive and laborious forms) would assist GPs in ensuring that they can efficiently coordinate the many aspects of health care required for their patients, should be an additional avenue of health care service provision development that should be prioritised by the new federal government.

  20. Genevieve Freer says:

    Fires are a hot topic in NSW today-Tony Abbott has volunteered to fight fires-what about the local Medicare Local-at home in bed.

    Surveys by Medicare Locals are irrelevant because they do not survey primary care. I know this because I am a primary health care provider and they do not survey my primary care services.

    Not Medicare and certainly Not local.

     

    .

     

  21. Neville Steer says:

    It is interesting to reflect on the development of a national Medicare Local bureaucracy. The successful GP Networks which had been developed and evolving over a period of 15 years were at a whim abandoned. Labor needed another Big Idea for health. There were no incremental approaches, no pilot areas trialled for a few years. Let’s be honest – if suddenly it was defunded we would hardly notice.

  22. DR. AHAD KHAN says:

      Dr. McCrae, how aptly you state – ” Let’s be honest – if suddenly it was defunded we would hardly notice.” – All I can say is this – ‘ amen ‘.

    Dr. Ahad Khan GP

     

  23. Paul Baker says:

    A few problems I have noticed in the comments so far is that we seem to assume that the ML is meant to provide support to GPs. Nothing could be further from the truth. My ML has no apparent desire to add to GP numbers or services to the rural and remote region I work in. Rather, it seems a way (expensive and duplicative) to provide funding for allied health professionals such as physio and podiatry. I would be very happy if this system could attract physios, psychologists and the like to my region.

    I think my ‘local’ ML has some major issues in providing these services they promise because there are very few allied health workers wanting to work in this region anyway. I also believe that my ML has little time for actual funding of allied health services and a whole lot more for thoughtless community consultation forums where the ML rep talks at the community people that bother turning up in the middle of the day about how many allied health services they can fund and doesn’t let them know that there is no podiatrist to be found for 400kms! At least the state run health system’s consultation forums were held after 5pm so local people actually had a chance to put their views forward to the DON and Med Super when there was time to listen.

    Don’t get me wrong, I would love to see better allied health services and hope against hope that this system will provide it, but I can’t see my region’s ML having any great ability to provide it. But please be sure to know that MLs are not there to provide funding for GP services they promise great allied health services to work with us, but ultimately can’t deliver.

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