Anyone seen general practice?
Like trying to find your way when your global positioning device is unwell and you are assaulted with confusing half-messages – turn left at the intersection you have just gone through – we are struggling to get a clear sense of direction in general practice and primary care.
Divisions of General Practice made good sense – enable general practitioners to meet, share ideas, pursue continuing education and do things together that can be done best when not in isolation.
Then came Medicare Locals, with a more complex set of expectations, brokering multiple programs for the Commonwealth that were never effectively communicated. Even the name was weird. But before they were fully established to show what they could do – for example, tying care together between hospital and community for patients with chronic problems – they too have been unceremoniously ushered off the stage.
The next player to be auditioned is called Primary Health Networks, of indeterminate size.
What the PHNs are to do, what lines they are expected to speak in the great drama of health care, is not clear enough for anyone to whom I have spoken to tell me. In short, the lines – the policy – are simply not there to speak.
Into this tangle come private health insurers, bidding to fulfil the undefined role of PHNs. Presumably they see money in it. Does this mean that there is a policy for the future of primary care lurking in Canberra, and we have simply not been told what it is?
Or, more likely, are there only a bundle of disjointed tactics – privatise, make users pay, reduce Medicare and so on – that speak of an ideology that favours the private over the public, and so gives comfort to those insurance companies that are angling for part of the action?
So that is one set of confusing messages from our Tom-Tom. There are more. Two are especially troublesome.
First, there is the unsubstantiated belief that a great leap forward in the prevention of non-communicable disease can be achieved by a combination of preventive services offered in general practice and a stiffening of individual will-power and moral fibre as in “turn off the TV with the junk food ads, don’t buy so much alcohol and don’t smoke”. Evidence? None.
The huge gains necessary in food policy, urban design, transport systems, and much else that determine the environment we live in, and set the agenda for health and the decisions individuals make about their lives that prevent non-communicable disease have never had, and do not now, have anything to do with medicine.
So asserting that a national approach to these new pandemics can be mediated by the health care system – private or public – is not based on evidence.
This is what makes the loss of the Australian National Preventive Health Agency, with its capacity to engage these out-of-health players, such a wanton act of vandalism: it had the independence, the strength and the capacity to do the heavy lifting with industry and portfolios other than health. But it is now neutered and back in the federal Health Department.
Second, there is a touching belief that general practice and community care can save us from the tsunami of chronic illness that is now not far from our shore. Evidence? Next to none. Certainly the potential is there, as demonstrated in other countries, but look further.
Where integrated care works to reduce inappropriate use of hospitals there is one payer. An example is Kaiser Permanents with its managed care for six million Californians. Then there are the many McKinsey-supported projects in the US and the UK involving complete electronic data systems to assess clinical performance and health outcomes, guidelines and a keen interest in professional standards for all practitioners, rewards and sanctions. Pull any of these pieces out of the integrated care structure and the whole thing collapses.
We have none of these necessary arrangements. Like the out-of-health preventive measures needed to achieve non-communicable disease prevention, these qualities of successful integrated care are not within the power of general practice to achieve, whether that practice is embedded in a Commonwealth-funded PHN or a private insurance arrangement. They belong with the major State and Federal health bureaucracies.
Time for a reality check. Or cold shower. Or both.
General practice is too important for this amateurish messing about and having expectations fall on it like a meteor shower that it cannot be expected to meet.
We need an evidence-based social policy (as in P-O-L-I-C-Y) for general practice, fewer expensive consultancies with their glossy and trashy-worded weasel advice, and much greater clarity to protect this precious asset and set it free of bureaucratic tape and political thought-bubbles.
Oh. In case you are unfamiliar with the elements of good policy – the blood and breath of democracy – with its judicious mix of evidence, consumer views, contested ideas, economics and politics, read all about it at http://en.wikipedia.org/wiki/Public_policy.