SSWAHS = SWSLHD + SLHD and the Medicare Locals - 65

Is there a future for Medicare Locals Ink?

7th Nov 2011 Melissa Sweet   all articles by this author

Medical Observer 

THE suggestion below may sound unrealistic and more than a little self-serving. Even so, it might be worth considering this potential scenario, set sometime in the 2020s.

Medicare Locals, after some years of painful growing pains, have found their footing.
They have established systems to ensure a timely understanding of the wide range of factors affecting the health of their local populations, and they are working with a range of interests, including health services, to help address these. Some have also taken a step that many perceived as high-risk: employing journalists.

The journalists are not churning out the dull, worthy and generally unread reports, nor are they writing press releases and other marketing material. Rather, they are investigating and telling authentic, sometimes confronting stories about their local communities, taking a broad view of the factors affecting health. These include stories about education, employment, local environmental issues, resource allocation and efforts to make local sense of the tide of data that is being released under Gov2.0 initiatives.

The journalists are helping to inform and engage their audiences as well as to provide a forum for debate and discussion between the community, health services and other sectors.

Their work is also helping to join up the dots in a health system that still struggles with the impact of policy and service silos and fragmentation.

Of course, this may all sound like a desperate job creation scheme from a journalist who is painfully aware of her industry’s uncertain future. But I’m not suggesting that only professional journalists have a role at Medicare Locals Ink.

Enlightened Medicare Locals have recognised the role that citizen journalism can play as a population health intervention in its own right. These innovators were inspired by public health-building projects in Australia and other places that equipped community members with the skills to harness the digital revolution in the investigation and telling of stories.

Indeed, one such recent project, NT Mojos, was funded by the Australian government and gave Indigenous people from remote NT communities the skills and technology to tell their stories using iPhones. You can see some of these stories at http://ntmojos.indigenous.gov.au/.

Some Medicare Locals also took the plunge into publishing, having realised they had plenty to learn about public health communications and engagement from the corporate sector.

When McDonald’s launched its own TV channel for customers (as was recently announced in the US), many public health observers were alarmed by the implications. But others saw it as a lesson that in this era of do-it-yourself publishing, there are new opportunities for those with an interest in contributing to a more informed and useful debate about health matters.

As was recently observed by Dr Ivan Oransky, the executive editor of Reuters Health and founder of the blogs Retraction Watch and Embargo Watch, “a better informed public is a healthier public”.

Of course, there are any number of pitfalls between the idea and the execution of Medicare Locals Ink.

To make a difference, Medicare Locals would need to be publishing journalism (perhaps in collaboration with other like-minded organisations) that rocks the boat, challenges the status quo, and seeks accountability.

As Dr Oransky also noted, “in journalism, you’re not there to make friends with your sources, you’re there for your readers”. (His comments were reported in a recent interview with Other Doctors, a new US blog featuring “doctors who ventured outside the hospital”).

Clearly, Medicare Locals Ink would face some rather daunting barriers, especially as the health sector’s approach to communications has often been driven by a debate-suppressing, risk-management focus.

But it may prove to be timely that primary healthcare reform is evolving at a time of innovation and risk-taking in new media more widely.

Melissa Sweet
Freelance health journalist and editor of Crikey’s health blog, Croakey

 

 

Comments:

 

 

 

Dr Amanda, Sydney
7th Nov 2011
4:13pm

As always wonderful commentary. Primary healthcare restructuring (reform not happening yet) has had a wonderful basis for 10 years with Practice Based Research Networks. This has lost funding and there is reduced (near nothing) primary care research funding now in Australia.
Medicare Locals are not filling this research funding gap
Medicare Locals INQ (INQuiry = research) would be fabulous for the hundreds of GP and allied health care professionals involved in this long term research base (proven in Canada and USA) which has been discontinued for no given reason and with no substitute.
We are keen in Australia and have nowhere to go. All GP research depts at all Australian universities are united in working for this.
Dr Manda GP Sydney

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 42

A conversation we ought to be having about healthcare

May 5, 2011 – 5:40 pm, by Melissa Sweet

Anne-marie Boxall from the Commonwealth Parliamentary Library has written a timely and important article for the FlagPost blog, titled: Paying for health care: how can we sustain it?
It is republished below with her permission, and will be worth revisiting when the post-budget protests erupt.

Anne-marie Boxall writes:

At budget time, the federal health minister has one of the toughest jobs. We got a glimpse into this a few weeks ago when the Government announced that it had decided to defer listing some new drugs on the Pharmaceutical Benefits Scheme even though they work and have been deemed by experts to be cost-effective. The announcement sparked outcry from consumer groups and health care organisations alike.

The Minister found herself in this unenviable position because the amount of money available to spend on health care is finite. This is not just a dilemma that arises at budget time however.
Governments around the world are becoming increasingly concerned about how they will fund health care into the future because in most OECD countries, health expenditure is growing at a faster rate than gross domestic product.

The harsh reality is that we cannot afford to do everything that we want or need to do to improve people’s health, at least not without finding new revenue sources (for example from taxes, the private sector and individuals). As Minister Roxon explained last week, the constraints on public sector financing mean that governments will need to play a more active role in determining what will, and will not, be funded in health care. In health circles, this exercise is known as priority setting.
In a forthcoming Parliamentary Library Research Paper I examine the fiscal sustainability of the Australian health system in more depth. In addition to priority setting, I outline a range of mechanisms currently being used to help control health expenditure and examine how effective they are. I also outline a number of other options that could be considered, including:
• paying health care providers in different ways (there are numerous options but the World Health Organisation considers salaries, setting strict budgets, and using capitation payments to have the most potential for containing costs);
• stimulating competition between the public and private sectors, as long as it drives improvements in the quality of care and delivers better value for money;
• monitoring and exerting greater control over the capacity of the health system (for instance the number of health care professionals and health facilities makes a significant difference to overall health expenditure); and
• ensuring government funds are only used to fund the highest quality and most effective of all the treatment options (physiotherapy, for example, might be more effective for back pain than drugs or surgery).

One thing the paper makes clear is that there is virtually no easy savings to be made in the health care sector anymore. Doing anything to make Australia’s health system more affordable will be tough, so beware of anyone spruiking simple solutions. It is not simply a matter of compiling a list of the most cost-effective or cheapest treatments and funding them first. Other countries have tried this ultra-rational approach and found that decisions provoked so much outcry that they were politically untenable.

In the United States, recent attempts to make resource allocation in health care more rational led to claims that the government was introducing ‘death panels’. In the United Kingdom, the decision to deny access to certain cancer drugs led to similar claims. Even if governments hold out against such protests, often there just isn’t enough evidence available to make an informed decision about which treatments deliver the best bang for the buck.

Making the health system more sustainable is also not as simple as getting those people who can pay more to do so. Individual contributions, such as fees, co-payments and other out-of-pocket payments, already account for about 17 per cent of total health expenditure in Australia.

And there is already compelling evidence that the cost of health care poses a real burden for some people and stops them from getting necessary care (see here, here and here). Shifting more of the cost burden onto individuals would make it even more difficult for people with low incomes to get essential health care, and it would make our health system less equitable.

It would also mean that Australia was moving in the opposite direction to most other OECD countries, which have reduced the proportion of total health expenditure coming from individuals over the last decade. It’s not possible to explain the reasons for this trend without further analysis, but it may be that other countries have come to agree with the World Health Organisation that relying on individual contributions to control the growth in health care costs is a relatively blunt instrument and the least equitable way of funding health care.
With no easy solutions on offer, the only way this or any future government is likely to make our health system more sustainable is to undertake more fundamental and potentially unpopular reform (this would include considering some of the options outlined earlier).

Governments will have to make the public more aware that there are limits on what they can spend on health care. No one will like it when the funding cuts affect them, but it might help if they have some understanding of why. Governments will also have to convince health care providers that changes are needed so that better care can be provided at a lower cost.

If reforms threaten the incomes of health providers, then they may need to innovate and find new and more profitable ways of delivering services.

Governments will also have to initiate a national debate on some of the key issues that underpin the issue of sustainable health funding. Are we, for example, prepared to consider solutions such as paying more tax? Or, do we want to move away from public financing and encourage the private sector and individuals to play a greater role?

Admittedly, a reform agenda along these lines would be politically difficult for any government. However, it is likely to be more effective than the current approach.

To date, governments have tended to view the health system in its components parts because it is so large and unwieldy. As a result, there does not appear to have been an overarching strategy for reigning in the growth in health expenditure. Instead, it appears that governments have had a series of one off battles in various sectors of the health system over time.

Instead, governments could consider viewing the health system as just that, a system, and begin developing a clear strategic plan for how we as a nation will tackle the problem of ensuring the sustainability of the health system.

Given that just about any proposal for constraining health expenditure provokes outrage, when it comes to engaging in battles over health funding, it seems that governments would have little to lose by being strategic about the battles it takes on in order to deliver outcomes in the long-run.

One Comment

1. Dr George Margelis
   Posted May 5, 2011 at 7:33 pm
   
   It is great to see that the discussion has moved on to the real problem, The way we currently pay for healthcare in Australia and many other countries drives the current problem of increasing costs without driving better outcomes.
   Anne-Marie has summarised the option, what we now need is leadership to drive them through. The health cost problem is potentially much more dangerous than many of the other issues the government has turned its attention to. We can try introducing more taxes to help cover the costs, but at some stage you just run out of taxable income, so reform of the system now is really the only option.
   

SWSLHN and Bowral's Health - 1

Challenging accepted wisdoms about young peoples’ health and wellbeing

April 22, 2011 – 1:19 am, by Melissa Sweet

Mental health is in the political limelight in the lead-up to the federal budget, with the Government and Opposition both promising support for mental health services.

The researcher and writer Richard Eckersley argues that we need to develop a much broader understanding of mental health and wellbeing in young people. In particular, he challenges the conventional narrative around the social determinants of health.

***

Challenging the accepted wisdom about young peoples’ health

Richard Eckersley writes:

The widely accepted story of young people’s health in developed nations is that it is continuing to improve in line with historic trends and the progress of nations. Death rates are low and falling, and most young people say they are healthy, happy and enjoying life. For most, social conditions and opportunities have improved. Health efforts need to focus on the minorities whose wellbeing is lagging behind, especially the disadvantaged and marginalised.

There is another, very different story. It suggests young people’s health may be declining – in contrast to historic trends. Mortality rates understate the importance of non-fatal, chronic ill-health, and self-reported health and happiness do not give an accurate picture of wellbeing. Mental illness and obesity-related health problems and risks have increased. The trends are not confined to the disadvantaged. The causes stem from fundamental social and cultural changes of the past several decades.

The contrast between the old and new stories is graphically illustrated by these Australian statistics: about 40 per 100,000 young people (aged 12-24) die each year and the rate is falling; 26,000 per 100,000 (26%) (aged 16-24) suffer a mental disorder each year and the rate has probably risen, perhaps steeply. Which statistic says more about young people’s wellbeing?

Stories inform and define how governments and society as a whole address youth health issues, so which story is the more accurate matters. The usual narrative says interventions should target the minorities at risk. The new narrative argues that broader efforts to improve social conditions are also needed. The old story may still generally hold true in developing nations, but the issues raised in the new story are also of increasing importance to these countries as modernisation and globalisation impact more on the lives of their young people.

A central dimension of the changed trajectory in health over recent decades, and which underpins the new story, concerns the declining significance of material and structural determinants of health and the growing importance of existential and relational factors to do with identity, belonging, certainty and purpose in life. There is a shift in emphasis from socio-economic causes of ill-health to cultural; from material and economic deprivation to psychosocial deprivation; from a problem of material scarcity to one of excess. With this has come a shift in significance from physical health to mental health.

This argument is not to suggest sharp, categorical distinctions and clear breaks from the past. Physical and mental health are closely interwoven and interdependent. Physical illness, including infectious diseases, still matter. Disadvantage and inequality still matter. Indeed, the cultural changes of past decades may well have exacerbated their effects by making material wealth and status more important to how people see and judge themselves. Environmental problems such as climate change have serious implications, including the risk of possible catastrophic effects on human health.

The contrast between the old and new stories of young people’s health and wellbeing is part of a larger contest between the dominant narrative of material progress and a new narrative, sustainable development. Material progress sees economic growth and a rising standard of living as the foundation for a better life; sustainable development seeks a better balance and integration of economic, social and environmental goals to produce a high, equitable and enduring quality of life.

Material progress represents an outdated, industrial model of progress: pump more wealth into one end of the pipeline of progress and more welfare flows out the other. Sustainable development reflects (appropriately) an ecological model, where the components of human society interact in complex, multiple, non-linear ways. Not only does sustainable development better fit the new story of youth health, it is likely to achieve better outcomes in relation to the old story’s focus on socio-economic disadvantage and inequality because it less intent than material progress on economic growth and efficiency.

The health of young people should be a focal point in the larger contest of social narratives. They should, by definition, be the main beneficiaries of progress; conversely, they will pay the greatest price of any long-term economic, social, cultural or environmental decline and degradation.

If young people’s health and wellbeing are not improving, it is hard to argue that life is getting better.

• This is an edited extract from: Eckersley, R. 2011. A new narrative of young people’s health and wellbeing. Journal of Youth Studies. First published 13 April 2011 (iFirst) (http://dx.doi.org/10.1080/13676261.2011.565043). An author version is available at www.richardeckersley.com.au

• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.

SSWAHS = SWSLHN and mental health in the Southern Highlands - 12

Mental health: a continuing history of neglect

April 12, 2011 – 11:01 pm, by Melissa Sweet

Chronic disease prevention is gathering increasing steam, at a national and international level. So why is mental health not part of this agenda? Richard Eckersley argues that the importance of mental health continues to be neglected, and not only in Australia.

Richard Eckersley writes:

Physical and mental health are closely interwoven and deeply interdependent, the result of a complex interaction of biological, psychological and social factors. Medicine, however, continues to focus on the biological and neglect the psychosocial, despite the growing recognition of its importance to population health.

This artificial separation has been a formidable obstacle to understanding mental health; as a consequence, its importance to the wellbeing of individuals, communities and societies has been underestimated. Both developing and developed countries show this bias towards physical health, and especially mortality.

Developing countries tend to give priority in health to infectious disease and reproductive and child health; developed countries prioritise non-communicable diseases that cause early death (such as cancer and heart disease) over those that cause years lived with disability (such as mental disorders).

The relative neglect of mental health is seen in the growing efforts in disease prevention and health promotion, both internationally and nationally. These include: the WHO global strategy for the prevention and control of non-communicable diseases; the Oxford Health Alliance; the Trust for America’s Health (in a report, ‘Prevention for a healthier America’); and the Australian National Preventative Health Taskforce (in its strategy paper, ‘Australia: the healthiest country by 2020’).

All imply a wide health perspective, but focus on the physical diseases that contribute most to premature mortality, notably cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. These diseases account for about 60% of all deaths globally.

The efforts will culminate in the United Nations’ first high-level meeting of the General Assembly on chronic non-communicable diseases in September 2011, billed in Lancet as ‘a once in a generation opportunity to put chronic diseases on the global and national agendas’. These diseases have been ‘surprisingly neglected elements of the global-health agenda’. Mental illnesses, while also chronic, non-communicable diseases, are not part of this agenda, but are acknowledged to be ‘similarly ignored’.

About 450 million people worldwide are suffering mental illness; only a small minority receives treatment. Worldwide, community-based studies have estimated the lifetime prevalence of mental disorders at 12%-49%, and 12-month prevalence at 8%-29%. In 2004, neuropsychiatric conditions as a group accounted globally for 13.1% of the total burden of disease, measured as both death and disability (disability-adjusted life years or DALYs), the second largest contributor after infectious and parasitic diseases. They account for about a third of the burden of disability, making them the most important source. Depressive disorders are the third largest specific cause of death and disability (and the largest in high- and middle-income countries), and are projected to become the leading cause by 2030. Yet the median allocation of the total health budget of nations to mental health is only 3.8%.

The ‘global burden of disease’ study has played a seminal part in exposing the importance of mental health to overall population health. However, its estimates of the burden of mental illness may still understate its significance for several reasons:

• mental disorders might affect many more people than the burden of disease estimates suggest, especially in middle- and low-income countries.
• the estimates do not include the growing burden of suicide and self-inflicted injuries, which is counted under injuries.
• the burden of mental disorders (in sharp contrast to chronic, physical diseases) falls mostly on those under 60, so increasing the personal, social and economic costs.
• mental disorders increase the risk of physical diseases and injuries, with one estimate that depressive disorders raise the risk of all-cause mortality by about 70%, and affect adherence to treatment for other diseases.

Aspects of this picture of mental health have been contested. For example, it has been argued that the high prevalence of mental disorders reflects changed DSM diagnostic criteria and the medicalisation of normal human emotions. This is part of a wider concern about the medicalising of life itself, and ‘disease mongering’: the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments, including the medicalisation of health problems previously regarded as ‘troublesome inconveniences’.

While medicalisation is undoubtedly occurring in the sense that new treatments are being developed for new conditions, this does not negate the core argument here that mental illness has been neglected relative to physical illness. The charge of ‘disease mongering’ applies to both physical and mental health, and is directed particularly at treatment provision. Indeed, it has been specifically associated with a policy priority of market-based economic development at the expense of more equitable social policies, such as public-health strategies. (Ironically, the medicalisation of mental health has contributed to greater awareness of its importance.)

Questions of definition, diagnosis and treatment aside, the disability associated with mental health problems is generally higher than for other chronic conditions. Even mild cases cause levels of impairment equivalent to those associated with clinically significant, chronic physical disorders.

People attribute higher disability to mental disorders than to commonly occurring physical disorders, especially with respect to their ‘social and personal role functioning’ (with ‘productive role functioning’, the disability of mental and physical disorders is comparable). A comparison of the disability of 15 disease stages found severe depression ranked third behind quadriplegia and being in the final year of a terminal illness, and ahead of stroke and acute myocardial infarction.

• This is an edited extract from:
Eckersley R. 2011. The science and politics of population health: giving health a greater role in public policy. WebmedCentral PUBLIC HEALTH 2011; 2(3):WMC001697.

• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.

One Comment

1. carolinestorm@iinet.net.au
   Posted April 13, 2011 at 11:33 pm

   “… focus is on the physical diseases that contribute most to premature mortality.”
   So, are the seriously mentally ill to be allowed slowly to become more deprived of treatment and hospital care? Already only a third receive these when in crisis, according to the MHCA. Are they still to be deprived of psychotherapy, essential to to their well-being; are they further to be deprived of social therapies, and more and more descend into homelessnness and complete social exclusion? Why does focussing on the diseases which contribute most to premature mortality exclude the seriously mentally who, in Australia, have a life expectancy of some 55 years.
   More and more suicides will occur as the seriously mentally ill realise, finally, the greatest stigma of all: this is too hard; we’ll just leave it and see what happens.
   What can be done? How can we help? Many people care, but how do we become a force for change?
   But even hope lessens as Richard Eckersley cites the WHO as excluding mental illness from its global strategy of prevention and control of non-communicable diseases.
   The Australian Budget, 2011, is to be made public tomorrow…and little hope there.

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/

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SSWAHS = SWSLHN + SLHN and mental health in the Southern Highlands - 2

Socrates suggests that now the NSW election has produced the outcome that everyone knew was to happen, we carefully watch whether the Liberal-National coalition government delivers on its promised changes to improve mental health in NSW and in particular to the Southern Highlands community. Here is a reminder of what the, then, Government, and the, now, new Government promised the people of NSW.

What is on the table for mental health in the NSW election?

March 20, 2011 – 7:06 pm, by Melissa Sweet

The Mental Health Coordinating Council has been analysing the mental health policies of the major parties in the run-up to the NSW election (at least those released so far).

Thanks to Tully Rosen, the Council’s policy and research officer, and his colleagues for providing this summary.

Tully Rosen and colleagues write:

MHCC has gathered the details from the specific mental health policies announced by the major parties for the NSW election. Although the Greens have a mental health policy listed on their website, as far as we are aware they have made no specific program announcements. As usual, the funding directed by both major parties specifically to community managed organisations is only a fraction of the total new funds promised for mental health.

Liberal/National

• Establish a Mental Health Commission ($30mil)

This Commission will have full responsibility for mental health budget which will be quarantined. It will be able to focus resources on where they are needed and on the most appropriate models of care. The legislation to establish the Commission will be developed by a specially appointed working group. The Commission will have three specialist units to: manage the experience of patients and carers; divert mental health patients away from the prison system; and help ensure a smooth operation of the Mental Health Review Tribunal

• Extra funding for LifeLine ($8mil over 4 years) for telephone and counselling services

  Highlights for Community Managed Organisations – The proposed Mental Health Commission and quarantining of mental health funding will potentially be a good thing in the face of all the other health changes such as new local health areas and the ever present temptation to use mental health funding for other services. How funds for CMOs are quarantined or managed will need to be worked out. Funding for Lifeline is the only specific program or CMO mentioned (so far). All up extra for CMOs is $8mil over 4 years.

  ***

  Labor

• New public perinatal mental health service ($29.6mil over 4 years). This includes a new 8 bed mother and baby inpatient unit (location to be determined) and an expanded maternity and post-natal home visit program to support mothers at risk of post-natal depression.

• Doubling HASI (Housing and Accommodation Support Initiative) ($20.8mil over 4 years). Extra 1,100 places but no indication of support level mix or target groups.

• Setting up Assertive Community Response teams ($14mil over 4 years). Three pilot sites in Western Sydney, the Hunter and the Illawarra to deliver “community based” mental health interventions for children and adolescents.
  

• Family and Carer Mental Health Program extra funding ($8mil over 4 years). Extra funds for NGOs to provide these services.

• Expanding the number of Declared Mental Health Facilities throughout rural and regional NSW ($5.92mil over 4 years).

• Mental health research ($5mil over 4 years). $500K each year for leading schizophrenia researcher Prof Cyndi Shannon Weickert and $3mil to set up a Mental Health Clinical Academic Research Program.

• Expanding specialist Older Persons Mental Health Unit in the Hunter ($3mil).

• Continuing beyond blue national depression initiative in NSW funding for another year ($1.2mil)

• Expanding inpatient mental health infrastructure

  • A new Psychiatric Emergency Care Centre (PECC) at Blacktown Hospital

  • A Safe Assessment Room at Mt Druitt Hospital

  • A 20-bed sub-acute unit at Wyong Hospital

  • An additional 70 beds at Campbelltown Hospital and new mental health services as part of the Liverpool Hospital redevelopment

  Highlights for Community Managed Organisations – The major item for CMOs is the doubling of the HASI packages to 2,200. HASI is an effective program and its expansion is a good thing. The other main item for CMOs is the extra funding for the Family and Carer Mental Health Program. Beyond blue depression initiative is the only CMO specifically mentioned with this program being renewed for another year. Total extra funding announced for CMOs is $30mil over 4 years.

4 Comments

1. Murf
   Posted March 20, 2011 at 7:44 pm

   The MH Commission proposed by Lib/Nats sounds promising, but it would be good to know what sort of staffing they propose and how much salaries for them will cost; how often will they meet, what targets will they monitor, who do they believe will give the best value services to the various diagnostic groups (social workers, psychologists, family therapists, psychiatrists)? The rest of their plan sounds too vague to comment on.
   The Labor proposals are nicely detailed although they don’t state what sort of personnel will be providing services under the funded programs. I don’t like the idea that a specific researcher gets a great lump of funds they haven’t competed for on the open market, no matter how innovative or promising the program so far. Other researchers who compete for ARC and NHMRC money will be put offside! Better to provide salary and facilities for some research officers to be employed while directed by senior personnel already in NSW Mental Health. The Beyond Blue extension doesn’t sound enough to be meaningful since it must cover admin, communications, mental health workers and possible security- 12 months psychiatrist salary takes $250 000 already! The wonderful funding for the mothers/bubs program will have to be carefully allocated across buildings and staff as buildings cost a fortune- usually a lot more than first quoted for, especially when its all custom designed and built, not a couple of project homes cobbled together! I like the Labor proposals better than Libs, but it would help people deeply concerned about making the most of funds to see even more details and any flexibility with funds and personnel that may be shared with other health sub-sectors.

2. Melissa Sweet
   Posted March 21, 2011 at 6:57 pm

   Sally Rose, Blogger-in-Chief, Global Access Partners, asked me to post this comment on her behalf:

   Not working in the field I am only able to judge the relative merits of those lists by tallying the numbers. Painting a rough picture of a $38million + commitment from Lib/Nats VS a $79.52Million + commitment from Labor.

   Given that spending twice as much doesn’t always produce twice as much benefit, and given that there is never enough money in the budget for every worthy initiative to receive funding I’d like to pose a hypothetical question.

   Let’s imagine the funding commitments were met halfway and the Mental Health Coordinating Council was given the opportunity to outline how to spend $60million on improving mental health services in Australia how would you advocate spending it?

3. jass
   Posted March 21, 2011 at 7:32 pm

   At the moment, Western Australia is the only state with a mental health commission. Having been involved in the process – for a part of it anyway – my impression is that there are aspects of it which are quite promising. The old way of doing things in mental health is simply not working, and it is time to start something new. But in WA the commission does not have a legislative basis and the primary motivation is the government’s ‘markets are everything’ philosophy. so the commission becomes a market mechanisms, effectively, and a body that purchases services from mental health providers. the purchaser/provider relationship is thereby sharply divided.

4. Tully Rosen
   Posted March 21, 2011 at 9:12 pm

   Hi Sally,

   As we outline in our “Call to Action” position paper, there are a number of high-priority and cost effective programs that could be immediately invested in that would provide substantial benefit to people living with mental illness in NSW. To date, Labor has been more financially supportive of our identified priority areas, while the Coalition has committed to overdue broad structural reform. Neither is anywhere near enough.

   Our greatest concern, along with many many others in the mental health sector, remains that mental health overall is grossly underfunded – NSW remains around the bottom of the rankings for spending on mental health, for the percentage of mental health funding allocated to community mental health, and for the percentage of mental health funding allocated to NGOs. We need to be talking billions of dollars.

SSWAHS = SWSLHN + SLHN and mental health services in the Southern Highlands - 1

So you’re wondering what’s happening with mental health at a federal level?

April 1, 2011 – 6:08 pm, by Melissa Sweet

Note to readers: Please see author’s correction at bottom of the post.

At this time of year, there is always a lot of pre-budget jockeying. This year there is great expectation and also great apprehension about what the Federal Budget might hold for mental health.

Mental health advocate Professor Alan Rosen has been watching recent developments closely, and his analysis follows below (at the bottom of the post you will find an invitation to provide feedback to the Federal Government’s mental health advisors).

Professor Alan Rosen writes:

"The bookies seem to know what every election result will be. So why did we bother having Saturday’s NSW election? Couldn’t we just extrapolate from where the odds stand at midnight on election day?

"Then we could spend the Electoral Commission’s budget on our run-down mental health services. Maybe, on past disappointing form, we should not even wager our lunch on having much of a boost for mental health on budget night, despite Julia Gillard’s insistence that it is a 2^nd term priority. (Perhaps it should be called budget-smugglers’ night, to celebrate that dark art of sleight of the contents of taxpayers’ pockets?).

"But the longer the Government keeps postponing the crying need to reform Mental Health Services, the more that the growing affected community will keep raising the stakes. It is a dead-cert that it won’t just go away as an issue if ignored. In an international survey last year, foremost among all countries, the Australian public placed mental health services as one of its top 3 concerns, alongside the global financial crisis and climate change.

"Sensing the disquiet and impatience of the burgeoning Australian mental health constituency, Mark Butler, the federal Minister for Mental Health, recently put out an update letter about his deliberations with his expert committee, which said next to nothing about what they might be proposing in their advice to him, about which they were all sworn to secrecy.

"It may be that he is engaged in a delicate negotiating process to squeeze something substantial out of the tightening federal budget, but for what purpose?

"It is a bad move not to take this seasoned network into your confidence on your way. It is laudable that early in his tenure, Mr Butler did a whistle-stop tour around Australia, running brief group consultations in urban and regional centres.

"But that was before he installed his expert panel to develop these proposals. The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. He has commissioned a separate kitchen committee, derived partially from his expert group, to develop a “blueprint”, published not as a draft out there for consultation, but as time is of the essence in the budget build up process, as a finished submission to be taken urgently to Treasury, hopefully for funding*.

"There is a lot to commend in its striving for a transformative approach, and its shopping list of “evidence based best buys” for different age groups. So far so good.

"However, many of its proposed structures for adults though possibly promising, are substantially untested. We need time to produce some evidence that they work, because we don’t want to repeat the blatant wastage caused under Howard’s CoAG initiatives like Better Access, perpetuated by Nicola Roxon.

"Even more concerning is that the real firmly “evidence-based best buys” for adults with severe and persistent mental illnesses, especially with forensic, drug and alcohol comorbidities, have been left out. These include (acute) 7 day and night mobile crisis and continuity of care teams, assertive community treatment (rehabilitation) teams, and 24 hour residential respite households as an alternative to many admissions.

"The Blueprint group can’t back this trifecta, we are told, because their riding instructions stated that these are viewed federally to be state responsibilities, particularly since the states wouldn’t relinquish that 30% share of GST. This could almost be construed as a washing of hands in retaliation.

"At whose expense? These proven service delivery systems will become orphans, and many severely disabled clientele will continue to be clinically abandoned.

"Most states squandered the resources allocated for them long ago, by diverting them to medical and surgical procedures, and by failing to complete the disgorging of stand-alone institutions, preventing the shift of some of their resources to community care. With few exceptions, this has resulted in stunted development or dismemberment of such evidence-based mobile community-based mental health services, and often the retraction of their rumps back onto hospital sites.

"A little under $2 billion over 5 years is required to provide firmly tied funding to the states to restore these key teams, including rural adaptations of them Australia-wide, and to monitor, this time around, their outcomes and fidelity to evidence via a national mental health commission.

"Either that or they will need a contractual arrangement with the states to meet them half way if they want the money, not just via another CoAG agreement, which is bound to be broken.

"The AMA is completely right that we need at least a commitment of $5 billion over 4 years, partly to make up for lost time and lost people. Most in the mental health community would differ with some of the AMA priorities for this funding, however. By my rough reckoning we need at least $5.5 billion over 5 years to kick-start a national mental health program with reasonable expectations of success.

"Professors McGorry and Hickie are overly modest in their estimates of what is required to deliver an effective transformation of the mental health service system, saying they will settle for around $3.5 billion over 5 years.

"This government also needs to commit resources to:

• a widely consultative process, arriving at a rough consensus inside a few months, about priorities and a framework for a national mental health reform program for the next 10 years, integrating public, non-government and private, including fee-for-service sectors. By now, this national mental health taskforce should be out there seeking a broad consensus for this national mental health program. It must overarch the superficial revamps of the national mental health policy, plan and standards, all devoid of practical goals and timelines, which have been diluted and downgraded in political compromises between state and federal bureaucracies. Gillard & Butler & co, need to hunt the money, but they also should not waste this build-up of expectation, momentum and opportunity for really consultation leading to transformative reform. If we are really into social inclusion, we need to practice what we preach.

• a National Mental Health Commission, as also proposed in “the Blueprint” like New Zealand, Canada, and now Western Australia, and soon NSW too, which promotes the resourcing and monitors the implementation of the reform agenda at arm’s length from government, while constantly consulting with all stakeholder groups, and reporting on an all-of-government scorecard basis to the Prime Minister, Health ministers and parliament.(Link to Rosen et al 2010, International Mental Health Commission review).

• Regional integrative budget-holding commissioning authorities ( as established in New Zealand, the UK and now on a statewide basis in WA, and soon to be formed in NSW ) ensuring integration of all mental health and support services, by being able to purchase flexibly from all funding streams, public, non-government communally managed, and private health organizations if need be (Link to AHHA paper on Funding Methodologies 2008).

• We need government to find new resources to bring the mental health proportion of health budget, currently sinking from 8% to 6%, up to 13%, closer to the proportion of health burden due to mental ill-health, as most other developed countries have done.

"As clinicians, we need to follow the form and play the system squarely in the interests of our clientele and their families, in every age group and phase of care.

"And we don’t need yet another policy shoot-out between the parties to entertain the political punters.

"We need a consistent tripartisan commitment to integrated collaborative mental health care for the whole Australian community.

"So while we can’t yet bet safely on the fate of mental health in the federal budget, either way, let’s hope it romps home.

"*However, the authors have placed it in the public domain, and Professor Ian Hickie of the Brain & Mind Research Institute, Sydney, has now undertaken to invite and collate comments by email. Contact: Ian Hickie

TAMHSS (Transforming Australia’s Mental Health Service System, tamhssATyahoo.com.au) will take and list comments publically on its blog from Monday 4^th April 2011.

• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

2 Comments

1. achimova1
   Posted April 1, 2011 at 7:35 pm

   Interesting that the RANZCP was not asked to field a delegate.

2. Melissa Sweet
   Posted April 1, 2011 at 9:59 pm

   Correction from Alan Rosen:

   Note: It has been drawn to my attention that there is an error of fact
   in the 2nd part of the 7th paragraph. It should read:

   “The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. Meanwhile, a separate little committee, derived partially from the minister’s expert group, and including his designated deputy, Monsignor David Cappo, convened to develop a “blueprint”.