The good, the bad and the ugly of Medicare Locals. Pamela Wilson reports.
Pamela Wilson all articles by this author
LAST month, the medical profession finally got its first real glimpse of the Commonwealth’s vision for its new health reform tool, Medicare Locals.
The Commonwealth’s 21-page document, Guidelines for the Establishment and Initial Operation of Medicare Locals, gave a broad outline of what these primary healthcare organisations will be expected to do, how they will do it and who will govern them. It also formally invited interested parties to step up to the challenge.
So far, many health commentators agree the aspirations in the guidelines – although they are mere statements at this stage rather than policy – are promising.
Robert Wells, director of the Menzies Centre for Health Policy at the Australian National University, feels there is potential for Medicare Locals to better tailor services to communities. Given they will be tasked with identifying gaps in local services, there is a real opportunity for the new bodies to focus on disadvantaged populations, such as Indigenous or refugee patients.
“The guidelines seems to give Medicare Locals a much better role in working with the Local Hospital Networks in their area and state/territory government community health… and there is a greater capacity [to develop] a more localised approach to healthcare,” says Mr Wells.
Although pointing out the new bodies are not an end point in themselves, AGPN chair Dr Emil Djakic agrees Medicare Locals are the tool through which the Commonwealth’s national primary healthcare strategy can be delivered.
“Medicare Locals are going to be the organisational infrastructure that builds on what has already been happening in the division network to try and deal with some of these things which our existing system had not been addressing,” he says, referring to access, inequity, prevention, better management of chronic conditions and accountability.
But not everyone has been won over. The AMA recently took a strong stance against the formation of the new bodies, claiming none of the details released by the government about Medicare Locals explains exactly how they will benefit patients or communities.
AMA president Dr Andrew Pesce has in fact called for the roll-out of Medicare Locals – set to begin from 1 July – to be shelved until greater consultation with clinicians has taken place.
There are still too many unanswered questions, he argues, particularly on the issue of fund-holding and GP involvement.
The consensus among health commentators seems to be that while the initial framework looks promising, the true test of success will be in the program’s implementation.
They argue this will require the Commonwealth not only to ensure adequate and flexible funding for the new bodies, but also to ensure that Medicare Local executive bodies have an understanding of the integral role that general practice must play in their functioning, and in overall primary healthcare reform.
It is this last point – how involved general practice, and general practitioners, will be in Medicare Locals – that is weighing on everyone’s minds.
The Medicare Locals boards will be skills-based and not representative, meaning there are no mandated seats for GPs or other practitioners.
However it is widely hoped that clinicians with governance skills will put up their hands to be involved.
“Unless GPs are significantly represented on those boards, I think the concept will not work well,” says Dr Pesce.
RACGP president Dr Claire Jackson says the main query from the college’s GP members is the amount of support they can expect from Medicare Locals, given that they will succeed divisions of general practice.
“GP groups are obviously very keen to see Medicare Locals embrace a broader health professional network but not to lose sight of the fact… there needs to be a heavy emphasis on general practice as the central pivot for primary care service delivery in the community,” she says.
Eastern Ranges GP Association CEO Kristin Michaels, who hopes her Victorian division will be among the first successful 15 tenders, says that among her colleagues there is strong recognition that general practice must be highly engaged in this process.
“It’s about those skills you bring to the table, but ideally you want a couple of GPs with [governance] skills,” she says.
As confident as Ms Michaels is in the success of her division’s bid, she is not as optimistic about the Commonwealth’s claim in the guidelines that “over time, Medicare Locals will be given the capacity to use Commonwealth program funding flexibly”.
“We’ve not really seen the Commonwealth able to achieve that [flexibility in control of funding] completely in the past. It’s difficult for governments to let go of things,” she says.
Dr Djakic believes it won’t be clear how much control Medicare Locals will truly have until the Healthy Communities Report for each area is produced by the National Performance Authority.
“How much funding and flexibility will depend on what questions or accountability a Medicare Local has to have against the Healthy Communities Report,” he says.
There are also questions about the funding mechanisms of the new bodies, after Prime Minister Julia Gillard stated they would become fund-holding organisations in the future.
United General Practice Australia released a statement last month urging the Commonwealth not to introduce fund-holding arrangements for MBS and PBS.
Dr Pesce also told MO he was concerned that a lack of consultation with the profession on this issue by the Commonwealth meant fund-holding was being considered.
“There have been references to Medicare Locals as fund-holding. We were previously given reassurances that funding for medical services would be for primary care and not through primary healthcare organisations,” he says.
“We’ve tried to get clarification on that [from the government], we haven’t been able to.”
Another funding concern relates to the distribution of money for the after-hours reform with which Medicare Locals are being tasked.
Dr Djakic is urging the Commonwealth not to strip funding from those after-hours services that are working well and instead have a critical look at what it genuinely takes to sustain them.
Dr Pesce agreed that the Commonwealth shouldn’t try to fix programs that aren’t broken.
“We all recognise that after-hours care can be done better… [but] we have to be careful that where something is working, the change doesn’t harm that.”
Already, in every way, it seems Medicare Locals will not lock into a one-size-fits-all model.
Ms Michaels points out that among her colleagues in other divisions there is already a strong difference in opinion on things such as the organisational structure Medicare Locals should take, and whether divisions themselves will transition into Medicare Locals or contract as service providers.
No matter what model each division decides upon, one thing is clear: this is the end of divisions of general practice as they have been known for the past 19 years.
On 30 June 2012, funding to divisions – including the AGPN – will be transferred to Medicare Locals.
But it is expected that the new model won’t simply be the divisions program by another name.
“Medicare Locals have the capacity to do something bigger and better than divisions have been able to do… with a little bit more funding and more formalised relationship expectations,” says Ms Michaels.
The reality is that the true shape of Medicare Locals won’t be known until July this year when the first 15 are up and running.
Medicare Locals
What are they?
- There are 42 agreed boundaries (with the exception of Victoria and Western Australia). However, the final number may exceed the planned 57.
- $477 million over four years will be used to establish the Medicare Local network.
- Annual core funding for each will be about $171 million.
- They will be expected to have some common membership of governance structures with Local Health Networks (LHNs).
- Boards will comprise seven to nine members.
- Although not mandatory, an organisational membership – with community groups and local health services – is preferred over an individual membership model.
They will be required to:
- form strong working relationships with LHNs and Lead Clinician Groups to deliver coordinated healthcare;
- undertake certain responsibilities such as fast-tracking after-hours reform, driving telehealth services and supporting the development of e-health and GP super clinics;
- undertake analyses of gaps in health services in their area and provide evidence-based strategies to improve patient outcomes;
- participate in the performance and accountability framework, including the Healthy Communities Reports prepared by the National Performance Authority.
Some choice.
