Australia needs a multi-disciplinary and integrated approach to the primary health care challenges of the coming century. The new primary health care organisations known as Medicare Locals aren’t perfect (as most will admit) but they are a welcome first step to re-orienting the health system towards a more responsive form of primary health care.
Hell, the fact that there is even a major health reform focused on valuing primary care (not just hospitals, but stopping people getting there in the first place) is even occurring in Australia is something that should be applauded by all flavours of politics in Australia, it’s certainly welcome news to most of the public health community.
It is therefore disappointing that health minister-in-waiting Peter Dutton has announced the Coalition is committed to abolishing Medicare Locals. The deafening silence that came from the absent roars of support from organisations across the country seem to indicate the Coalition may have missed the mark on this one.
In fact, the more popular opinion among the public health community is that Medicare Locals are not going far enough. What is really needed is a more active form of primary health care organisation, one which can take a truly community-wide view of addressing health issues.
Fund-holding and encouraging community organisations to have a greater say in providing and planning health services is another role we should be looking at for Medicare Locals, although the Coalition has already made it clear that it is not comfortable with this model, even before Dutton’s Friday announcement.
Oddly, in the same statement the Coalition seem to be the only group who think that moving away from the fee-for-service model for payment of health services is a bad thing. Even US health reforms are providing incentives to move away from this out-dated system of health funding, which serves only to provide perverse incentives for overtreatment and make clinicians unaccountable for their actions. It’s a worrying situation when the US seems more committed to health reform and improving access to health services than one of the major Australian political parties.
However, Medicare Locals are the first step to making such important reforms and improving primary health care delivery in Australia.
This isn’t to say that the roll-out of Medicare Locals has not been without its problems. But the largest problem at the moment is not the role that they can play; it’s that some of them aren’t playing it.
For every Medicare Local committed to expanding its role and making itself accountable to addressing community health needs (Metro Brisbane North is a good example of a high-performing Medicare Local), there is a division of general practice that is refusing to transition into their role as a Medicare Local. This is quite an important distinction, considering that divisions were charged with looking after primary care providers, whilst Medicare Locals are charged with improving primary care in the community as a whole. This creates problems as generally divisions have been awarded the tenders to create their local Medicare Locals.
Some divisions are evolving, and looking forward to serving general practitioners to complement the roles of Medicare Locals. But others are too busy protecting their own personal fiefdoms (a problem when multiple divisions have had to merge to create a Medicare Local), desperately trying to improve the relevance of their organisation in a post-division world, or are sometimes just being resistant to change (as is natural in human nature) rather than focusing on improving health outcomes in their communities.
The fact is that most well-managed Medicare Locals have been able to continue the public services of divisions, often with the same staff; for many in the divisions the real problem seems to be that they no longer control these programs — or the government payments that come with them — rather than actual disappearance of services.
Additionally, the Medicare Local model is being unfairly blamed for the mismanagement of individual boards. For example, yesterday the Medicare Local reforms were blamed for putting services and jobs at risk, when in reality it was the result of infighting of the two partner organisations involved in a contractual dispute.
This is not the fault of the Medicare Local model, but the fault of a few independent organisations and individuals. The Coalition should be supporting government efforts — or pushing for them if the efforts aren’t there — to bring these boards into line and making them more accountable to the communities they serve, rather than scrapping the entire model.
Unfortunately, if the government does ultimately take action against mismanaged Medicare Local or division boards it is likely to be portrayed by a compliant medical media as a threat to services and jobs, rather than necessary steps to ensure Medicare Locals are actually serving their communities. In fact the only major groups that have been consistently against Medicare Locals are the Australian Medical Association, disenfranchised divisions and the medical media, and it is therefore probably no coincidence Dutton chose to make his announcement at the AMA conference.
However the reasons for their opposition are far more about politics than they are about public health. The Medicare Local reforms are a comprehensive shake-up of the primary health care status quo in Australia, and it is therefore unsurprising there is controversy. Considering the AMA is a union of medical practitioners rather than a health organisation (though many often confuse the two roles), this opposition is hardly surprising.The expansion of Medicare Locals’ role to co-ordinating non-medical practitioners in the delivery of primary health care by including allied health providers, community pharmacists, nursing professionals and community organisations in the healthcare milieu offers enormous benefits to the patient but has left those who currently sit atop the current hospital-centric, medico-centric health system uneasy.
But the status quo has not been working, and the skill-sets required for co-ordinating primary health care services and delivering front-line clinical care are very different. The establishment of Medicare Locals is not an unnecessary layer of bureaucracy but a necessary step to ensure that clinicians are able to focus on delivering the care they’ve been trained to do and that their services are made accessible to the local community.
Doctors are great at delivering front-line medical services and addressing individual patient needs in clinical practice but are not necessarily equipped to co-ordinate primary health care at a community level. Putting clinicians back in charge of community health planning may seem like a good idea to the clinicians themselves, but the literature suggests that this is not necessarily the case.
A Norwegian study of primary care organisations found that leadership teams with qualifications focused on clinical skills tended to manage by exception (acting only when results deviated from planned outcomes) rather than building health outcomes in the community and nurturing relationships with existing community health organisations to improve social and health determinants.
Even collaborations of front-line clinicians — the pre-Medicare Local solution to after-hours primary care — may not be the answer to addressing primary health care gaps, and do not necessarily equate to better health service provision. Without formal performance measures, co-ordination or incentives such collaborations may be formed to provide benefit to service to providers rather than patients, for example providing the same level of service with fewer organisational resources or fewer overtime hours for individual clinicians, rather than focusing on improvement of services at a community level.
Anyone that’s worked with Medicare Locals knows that they are hardly the Canberra-centric automatons that Dutton would have us believe. As Australian Medicare Local Alliance chair Arn Sprogis outlines in his response to Dutton, Medicare Locals are exactly that — local — and are accountable to their communities and the public; with a strong focus on building grassroots links to build healthy communities in addition to providing improved primary health care services.
Nor is the role of doctors at risk from Medicare Locals. The notion that moving to a multi-disciplinary health system that uses each provider to their full potential and re-orienting Australian primary care to focus on the patient rather than primary care provider is somehow devaluing the role of the medical practitioner is laughable.
Medical practitioners will always be at the centre of primary care in Australia. Better co-ordination of primary care will simply allow them to be used to their full potential and stop them wasting both their time and efforts on tasks that can be better or more efficiently performed by other professionals.
Dutton’s retort is that he would like to take the money “wasted” on Medicare Locals and pump it straight into front-line medical services. However, more health services will not equate to better health service provision without the kind of co-ordination Medicare Locals can provide. If Dutton doesn’t want Medicare Locals to do it then who will?
The opposition would be much better served addressing the problems that exist in the current health reforms and allowing Medicare Locals and other agencies to get on with the jobs they were created to do, rather than dismantling important and necessary health reforms. Stop drinking the AMA Kool-Aid and start developing community-focused strategies and policies that can actually help address the primary care challenges of the future, not just breaking down reform for political purposes.
Otherwise the opposition are going to find that finding the $70 billion to fund their pre-existing commitments is going to be a lot harder if their short-sightedness on primary health care reform increases the financial burden health places on the Australian budget.
*Jon Wardle is a NHMRC Research Scholar in the School of Population Health at the University of Queensland. He has been a consultant for Metro North Brisbane Medicare Local as a population health data analyst.