SSWAHS = SWSLHN + SLHN and the Medicare Locals - 38

Health reforms walking a weak and wobbly plank

by Andrew Pesce

16 Apr 05:50am

The Federal Australian Medical Association opposes the Government’s Medicare Locals as currently proposed.

What happens if you take the doctor out of the picture?

There is little detail on structure or funding. There is no explanation of patient benefit. There is plenty of uncertainty.

Medicare Locals are supposed to be a major plank of the Government’s health reforms. It is a weak and wobbly plank.

We have called on the Government to defer the establishment of any primary health care organisations (PHCOs) until there has been genuine consultation with the medical profession.

The AMA has for some time been calling for consultation and more detail about the governance and operation of Medicare Locals, but those calls have been met with silence.

The AMA and the medical profession cannot support primary care reforms that do not explain how they would benefit patients or communities, and which do not guarantee they would maintain and support the leadership role of GPs in primary care.

There must be meaningful dialogue with the medical profession about a way ahead that is best for patient care.

The AMA is not opposing the concept of a primary health care organisation to coordinate primary care services. When Medicare Locals were first announced, we were cautiously optimistic about the role they might play in improving health care for Australians.

But since that time there has been little detail about governance, funding arrangements, or the envisaged role of doctors in their management. It is a big ask for us to support a concept that is very short on principles, let alone detail.

Some commentators seem concerned that the AMA insists that doctors should be strongly represented on the governance structures of our health systems.

You need only look at the chaos wrought upon our public hospitals when they are administered without appropriate reference to the doctors (and other health workers) who actually deliver the health services in the hospitals.

New Zealand’s initial experience with PHCOs that were run by ‘skills-based’ boards was heading for disaster until the situation was retrieved by an increased presence of doctors on those boards.

The assumption that health care is improved by marginalising the role of doctors in decision making is, to say the least, contestable - and the AMA will certainly continue to argue against it.

Locally, we examined closely how the proposed Medicare Locals were intended to integrate with Local Hospital Networks. Our examination was not too encouraging – hence our concerns.

Medicare Locals will be funded separately, governed separately, and will function separately to the acute hospital system.

The chances of evolving a Medicare Local-inspired integrated health system are just about zero.

The likelihood of continued cost and blame shifting between the Commonwealth and the States is extremely high.

The Prime Minister has also stated that Medicare Locals could be fundholding bodies and, despite our requests, she has not ruled out fundholding for GP services.

Currently, patients decide when they need a GP service, not a distant bureaucracy that works to a fixed budget, and which increasingly emphasises cost control rather than access to quality services.

This is a big change in the way a patient’s visit to a GP is funded. The community needs to understand that this will inevitably lead to the rationing of GP services – in the just the same way as public hospital services are rationed.

Although Medicare rebates have failed to keep up with the costs of providing GP services, patient co-payments, where necessary, have kept general practice viable.

Fundholding arrangements delivered by Medicare Locals could be the final straw that breaks the back of general practice.

Doctors practise according to the principle of ‘first do no harm’. Perhaps the Government should apply the same principle to its currently proposed Medicare Locals.

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 22

Here is more on the Medicare Local debate: Should we have them, who should run them, what are the benefits and what are the losses for the communities which they will serve? Will they just be another name for the Divisions of General Practice?

If we acknowledge that there are set criteria for their establishment we, in the Southern Highlands, can see that the CEOs and Boards of the Southern Highlands and Macarthur Divisions of General Practice appear to be taking the view that the funding they get will simply extend their Division's power and influence without necessarily improving the health outcomes for their health consumers.

On the other hand, the Bankstown GP Division continues to adhere to the guidelines for the Medicare Locals and has established a coalition of health services and agencies to bring about real change and collaboration in the access to, and delivery of, reformed health services in the SWSLHN area.

A reality check for the AMA’s contrary stance on Medicare Locals

March 21, 2011 – 6:33 pm, by Melissa Sweet

The timing of the AMA’s dummy spit about the new primary health care organisations to be known as Medicare Locals (MLs) was impeccable. The AMA announced last Friday that its Federal Council had voted to oppose MLs.

AMA President Dr Andrew Pesce said the AMA could not support primary care reforms that “do not guarantee they would maintain and support the leadership role of GPs in primary care”, and warned against any moves to fundholding.

The timing was impeccable because it so superbly illustrated the points made by a number of speakers at the national rural health conference in Perth last week – about the need for a more prominent place for the community in health debates, to try and counter the voices of the overly powerful vested interests. (You can see some of these comments in this previous Croakey post, quoting presentations from the Centre for Policy Development’s John Menadue and the University of South Australia’s Professor Robyn McDermott, although they were far from the only presenters making such comments).

Notably, some of the priority resolutions put forward by the 1,000-plus people attending the conference were supporting not only Medicare Locals but also models of care not based upon the AMA’s holy grail of fee-for-service.

The Australian Health Care Reform Alliance (AHCRA) has issued a statement expressing its disappointment with the AMA’s stance on Medicare Locals and fund-holding, and hoping “that the AMA will reconsider it positions to more forward-looking and collaborative ones”. The AHCRA statement also noted that “the future of health care is about teamwork”.

Meanwhile, health policy Jennifer Doggett suggests that perhaps we should read the AMA’s screams of protest as the mark of good health policy. If the AMA isn’t complaining, then presumably the status quo isn’t threatened…

The AMA: not exactly famous for its leadership in health reform

Jennifer Doggett writes:

"The Australian Medical Association (AMA) continued its tradition of opposing key health reforms when its Federal Council voted last week to oppose the establishment of Medicare Locals.

"Just as in the early 1980s it opposed the introduction of Medicare and in the 1940′s argued that the proposed Pharmaceutical Benefits Scheme (PBS) represented a dangerous slide into socialism.

"Thanks to these programs, Australians now have access to universal health care and some of the cheapest medicines in the developed world.

"Had the governments of the day bowed to pressure from the AMA and scrapped those planned reforms, we may well have ended up with a health system like the USA’s which costs more than double that of Australia’s and delivers poorer health outcomes.

"Luckily for the Australian community, the Health Ministers at the time were able to resist pressure from the AMA’s scare campaigns and propaganda machine.

"They pushed ahead with the introduction of these health programs which greatly benefited the Australian community and which are the envy of many other countries today.

"Even the AMA eventually agreed that perhaps there were some benefits to publicly subsidised health care. It’s hard to find an AMA spokesperson today who will publicly advocate the abolition of these programs.

"Similarly, the objection to Medicare Locals (MLs) is likely to turn out to be short-term paranoia about doctors losing control over the health agenda rather than substantial objections to the detail of the ML initiative.

"The fact that there is strong support for MLs among many other health groups – including some representing GPs – demonstrates how isolated the AMA is on this issue.

"In fact, the main concerns of other health groups about MLs are precisely the opposite of the AMA’s. They are worried that they will simply entrench the power of the medical profession in the primary care sector and fail in their stated aim to support better integrated and coordinated primary care.

"For example, the Royal College of Nursing Australia recently wrote to all political leaders describing Medicare Locals as ‘a reconfiguration and rebranding of the Divisions of General Practice’ and stating that it was ‘unconvinced that Divisions would be able.. to achieve the organizational cultures and attitudes required…to genuinely and effectively coordinate multidisciplinary health care’

"You don’t have to be Machiavelli to see that this tactfully worded letter is code for ‘don’t let the doctors take over’.

"The fact that the AMA is opposing Medicare Locals for not being doctor-focussed enough and other health professional groups are concerned that they are too doctor-centric, shows how tricky this area of health policy can be. It also is good evidence that the Government has probably made the right judgement about how far to push the reform agenda, at least from a political perspective.

"The political juggling act needed now is to progress the needed changes without getting the AMA offside to the point that it undermines the reform process while also not alienating other health professional groups by bowing to AMA pressure to maintain medical control over primary care budgets.

"It’s a difficult challenge but Nicola Roxon and her colleagues should take heart from the lessons of the past that it is possible – and indeed sometimes necessary – to deliver major health reform in the face of resistance from the AMA.

"In fact, looking at the public support and longevity of both Medicare and the PBS, it could be argued that the AMA’s opposition to a proposed health reform is a good predictor of its success.

"On this basis, it’s likely that one day the AMA will come around to supporting MLs, just as they did with Medicare and the PBS.

"It might just take them a little longer than the rest of the community.

5 Comments

1. Andrew Pesce
   Posted March 22, 2011 at 12:58 am | Permalink

   Before people accept what has been written here, perhaps they might actually
   read the AMA statement which stimulated this piece.

   http://ama.com.au/node/6494

   If they do, they will see that the AMA is not opposing the concept of a PHCO
   to coordinate primary care services.

   They might also note that our initial response to the announcement of
   Medicare Locals was cautiously optimistic about the role they might play in
   improving health care for Australians.

   http://ama.com.au/node/6433

   Many seem concerned that doctors insist they should be adequately
   represented on the governance structures of our health systems, but we only
   need to look at the chaos wrought upon our public hospitals when they are
   administered without appropriate reference to the doctors (and other health
   workers) who actually deliver the health services in the hospitals. Garling in NSW, incidentally, was not an agent of the AMA

   The statement that the Rural Health Alliance “has great hopes for Medicare Locals” is hardly an ringing endorsement of the announced structures, even if they do manage to change the name. And AHCRA’s comments contained as much criticism of the Medicare Local structure and function as it did of the AMA’s position.

   Inconvenient truth 1. New Zealand’s initial experience with PHCOs run by
   “skills based” boards was heading for disaster until the situation was
   retrieved by an increased presence of doctors on those boards.

   Inconvenient truth 2. Medicare Locals will be funded separately, governed
   separately and will function separately to the acute hospital system. Chance
   of evolving a ML inspired integrated health system: just about zero. Likelihood of continued cost and blame shifting between commonwealth and states: extreme
   Like it or not, the assumption that health care is improved by marginalising the role of doctors in decision making is to say the least contestable, and the AMA will certainly continue to argue against it.

   Andrew Pesce
   President, Australian Medical Association

2. Tim Woodruff
   Posted March 22, 2011 at 8:22 am | Permalink

   Whilst the negative response of the AMA is to be expected, it is hard for those interested in genuine health reform to become too excited by Medicare Locals. The vision is limited, the plans are sketchy at best, and it is hard to know whether MLs will be just another white elephant or worse.
   Regional entities could have the capacity to pursue the Federal Government’s rhetoric of ‘central funding, local control’. Unfortunately, the current plan is more likely to result in central funding and control and local blame.
   It is proposed that MLs will be engaged in population health planning. That requires knowledge of health needs which is also flagged. But there is no mention of information on current health spending at a regional level. (Remember how hard it was to get the Government to put in expenditure on the MySchools website). With health expenditure data at a regional and subregional level we would see the very stark inequities which exist in health funding and could plan to address them. That could then form the basis for health planning.
   Governance of MLs remains vague especially with respect to consumer and citizen involvement. This is partly because the Government has no national policy framework for consumer involvement and generally pays lip service to the concept. The transition of MLs from Divisions inevitably means that governance will be biased towards control by general practitioners currently involved in Divisions. Whilst this may work well in some regions, it is hardly the best way to achieve balanced governance with all stakeholders well represented.
   There are no plans for MLs to have sufficient funds at their disposal for them to exert much influence on current models of care. Whilst it will take time for MLs to build the capacity to use funds appropriately, it does not appear to be a significant part of the vision. In addition, they will be relatively powerless in their relationship with the well funded Local Hospital Networks. This is despite the rhetoric that we need a much greater emphasis on primary health care.
   The recent backflip by the Federal Government to abandon its plans to take over all primary health care funding will now mean that MLs will have to work with three levels of government in their co-ordination and integration role. That role would be hard enough with one level of government funding everything. It will now be even harder.
   Adequate data, resources, governance, and needs based funding at a regional level with national standards including for marginalised groups are required for MLs to evolve into anything useful.
   Where is the vision?

   Tim Woodruff
   Vice President
   Doctors Reform Society

3. rechoboam
   Posted March 22, 2011 at 7:12 pm | Permalink

   Could the author please explain in 25 words or less what a Medicare Local is and does?

   After Medicare Gold, the epic COAG reforms that never quite occured, the federal takeover that Rudd threatened, which never occured, I’m very confused by this government’s plans and have not seen a single example of how MLs or anything else will actually relate to human beings and their health requirements.

4. rechoboam
   Posted March 22, 2011 at 7:15 pm | Permalink

   For example I googled Medicare Locals and this is an example of what I found:

   “The South West Sydney Health Coalition has recently been made aware of certain assertions made by the Macarthur and Southern Highlands Divisions of General Practice concerning the formation of a Medicare Local in south west Sydney.

   The purpose of this letter is to inform you that the South West Sydney Health Coalition denies each of these assertions categorically as being completely without basis in fact.

   The Macarthur-Southern Highlands Divisions are not the official bid for the South West Sydney Medicare Local. The Macarthur-Southern Highlands Divisions do not enjoy any exclusive right to lodge a bid for a Medicare Local covering the Bankstown, Fairfield, Liverpool, Campbelltown, Camden, Wollondilly, and Wingecarribee local government areas. “

5. Melissa Sweet
   Posted March 24, 2011 at 11:35 am | Permalink

   Hi Rechoboam

   Take a look at this previous Croakey post which links to a series of posts about Medicare Locals: what they’re intended to do, and debate about how they will work etc.

   http://blogs.crikey.com.au/croakey/2011/03/03/a-comprehensive-analysis-of-the-plans-for-medicare-locals/

One Trackback

1. By On Medicare Locals, it’s time to seize the day, says rural health lobby – Croakey on March 25, 2011 at 4:24 pm

   ...] noted at Croakey recently, the AMA’s Federal Council has voted to oppose the establishment of [...

SSWAHS = SWSLHN and mental health in the Southern Highlands

Socrates says: "It's great that the National AMA is prepared to put forward the case for more funding, but not all mental health services are provided from general practices in this country."

If we are to have a more egalitarian mental health service we do need to engage the other parts of the private sector in the treatment and support of persons with a mental illness.

Likewise, we need to ensure that part of the funding goes to support the carers of the persons with the mental illness. Mainly because they provide the 24/7 care and support to the person and not the clinicians in the private or public health sectors.

Finally, let's ensure that the public health sector has the finances and the staffing levels to provide a better mental health service to the persons with the mental illness. The level of mental health beds available in the state of NSW is currently abysmal, with one of the highest populations and the lowest number of available beds per 100,000 in the country. With the changes in the state's parliament it's time for a new broom to sweep away the dinosaurs who have held back NSW from taking the lead in improving mental health outcomes for people with a mental illness.

As far as the Southern Highlands is concerned I hope that the new broom sweeps through the Concord Hospital Centre for Mental Health and removes some of the incompetents there.


Mental health needs more funding, services: AMA

29th Mar 2011

Andrew Bracey all articles by this author

1 comment

THE AMA has called on the Federal Government to provide $5 billion in funding to expand, better resource and coordinate mental health services.

The money would be used over four years to increase MBS rebates for GP consultations relating to mental health issues, to better reflect the complexities involved and meanwhile support public campaigns to reduce the stigma attached to mental illness.

The call came as the association today unveiled its latest position statement on mental health which included a range of priority areas for government action in mental health policy.

The AMA plan also backed previous calls by mental health campaigners including Professor Patrick McGorry to expand the number of community-based youth mental health Headspace centres and the number of Early Psychosis Prevention and Intervention Centres.

Phone counselling services would also be expanded under the AMA plan.

AMA President Dr Andrew Pesce said that Australians with a mental illness deserved to have ready access to quality individualised mental healthcare.

"This requires a significant expansion of services, intervention and support across the whole continuum of care for people with mental illness," Dr Pesce said in a statement.

"This also requires a significant funding boost to address the gaps in our current mental health services and enable the delivery of comprehensive, integrated and coordinated mental health services for all people who may develop an acute or chronic mental illness at any stage of their lives."

The AMA's position statement, which also discusses the need for greater government action across areas such as prevention, early identification and intervention, community-based care as well as acute and sub-acute care, can be accessed at: http://ama.com.au/node/6524

Comments:

Bibiana
29th Mar 2011
4:53pm

It is great to see AMA taking a strong stand in pushing the Federal Government for more injecting more funding into mental health services at Primary Care level. It was Oct 2008 at the WONCA Conference in Melbourne that WHO launched their report "Integrating Mental Health into Primary Care - A Global Perspective". In the report it provided 7 good reasons for such integration. On top of the list is 'the burden of mental disorders is great'. In my view as a consumer, the most important reason is 'Primary care for mental health promotes RESPECT OF HUMAN RIGHTS'. This is in-line with AMA's call for more funding to support campaigns to reduce the stigma attached to mental illness.
I recently attended a mental health forum 'What happened to mental health under Gillard?' in Sydney, one of the speakers was Prof Ian Hickie. He highlighted his 'Love and Hate' relationship with the Federal Government (and all the PMS and Health Ministers involved). The current government is exhausted in fixing too many unpopular policies (carbon tax, mining super tax etc), the Health Reform has to give way and let alone mental health. In his concluding remark, Prof Hickie pointed out the obvious - if the Government is smart enough to fix the long overdue mental health problems, many of the physical health issues will become more manageable and not vice-versa!

To download WHO's report, go to the following link:
http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 15

Building the future of healthcare

28th Mar 2011

The good, the bad and the ugly of Medicare Locals. Pamela Wilson reports.
Pamela Wilson all articles by this author

2 comments

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.

Comments:

Dr Manda
29th Mar 2011
8:28am

Does the $477m include what was spent on Divisons etc or is it on top of? How many more bureaucrats or other health professionals are going to be paid from this money to ensure MLs run as per primary care "changes" (not reforms till proven please!? Dollars given usually contain political spin.
Dr Manda, Sydney

Dr Manda
29th Mar 2011
9:08am

The ALP rants eternally about "equality of access". It uses this as a pretext for nationalising medical care. This benefits middle class lefties only, not the poor. But even the cockatoo who sits on my back porch every morning can see that Medicare Locals are Stage 2 of the socialisation of medicine. The public hospitals have been impoverished by Medicare. General practice is next. What brand of socalism we end up with depends only on who owns the facilities and employs the doctors. if it is the state, we become International socialists( i e Communists), or if the Medicare Local facilities are left in corporate hands, we are "only" National Socialists (that is, Nazis).
Some choice.