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 - 2

The difference between the advocacy of the Chair of the Bankstown Division of General Practice and the deathly silence of her counterpart in the Southern Highlands Division of General Practice is extraordinary. For one, Dr Susan Harnett made a submission to the NSW Health in respect of the Carla Cranny and Associates Report about the Medicare Locals boundaries. The Southern Highlands Division's report was notable for its absence in the process.

Secondly, Dr Harnett wrote eloquently about the diversity and cultural mix of the communities their GPs served and expressed the general feeling that they could be effective advocates for their patients with the local hospitals, ancillary services and allied health providers. Whereas, the silence of the Southern Highlands Division of General Practice would suggest that their own interests are more paramount than the interests of their patients.

Here is the full text of the submission made by Dr Susan Harnett. It gives a clear explanation of the plans for the Medicare Locals and provides a sensible alternative to the mega Medicare Local with which we now appear to have been given.

Submission by Dr. Susan Harnett (Chair, Bankstown GP Division Inc.)

Principles for determining boundaries or catchment areas for Medicare Locals, including potential differences between metropolitan, rural and remote areas (eg size of catchment populations, natural catchment areas)

"We believe that three distinct Primary Health Care Organisations in south west Sydney will provide the optimal configuration for state and federal primary health care policy implementation over the next 10 years to 2020 and potentially beyond.

"As outlined in the NSW Health and Commonwealth discussion papers, the three PHCOs will be based on Local Government Area (LGA) and Sydney South West Area Health Service borders, current patient flows, transport corridors, demographic congruence, and projected population growth. Based on these characteristics the evidence indicates that the three PHCOS should be:

i. A Central Sydney PHCO based on the existing Central Sydney Division of General Practice.

"This PHCO will cover the relatively affluent areas extending from the CBD across the inner west. This includes the border suburbs of Lakemba and Canterbury and similar where local tailoring of services for specific areas of need can be appropriately managed by this PHCO, without creating a massive challenge for efficient administration or governance, which would result from a larger area.

ii. A South Western Sydney PHCO based on the amalgamation of the existing Bankstown and Fairfield- Liverpool Divisions of General Practice.

"This PHCO will focus on providing services to the well established urban communities in the Bankstown- Fairfield- Liverpool corridor which have a very high proportion of CALD residents and specific areas of health disadvantage due to their relatively low-SES and related factors.

iii. A Macarthur-Southern Highlands PHCO based on the current Campbelltown - Bowral area LGA’s as defined by the Divisions for future PHCO boundaries.

This Campbelltown-based PHCO will focus on establishment and provision of primary health services in a growing region of Sydney, including part of the South West Growth Centre, Campbelltown, Camden, and adjoining suburbs with outreach to the border limits of the current Southern Highlands Division.

"The National Health and Hospitals Reform Commission’s Final Report, A Healthier Future for All Australians recommended that PHCOs “be of an appropriate size to provide efficient and effective coordination (approximately 250,000 to 500,000 population) depending on health need, geography and natural catchment”.

"In this context, the proposed South West Sydney PHCO (Bankstown-Fairfield-Liverpool) would have approximately 300 practices (~560 GPs) serving a population of approximately half-a-million residents (570,000 calc)

Suggestions about the optimum number of Medicare Locals in a particular state, territory or region, including potential boundaries in each area

"The report commissioned by AGPN (Carla Cranny 2010) provided options for PHCO sizes and configurations which were focussed on massive population numbers and assumptions of scale that were not evidence-based beyond aggregating numbers for LGAs, Divisions and PHCOs as massive regions.

"Whether the number in NSW is 15, 16 or more or a total of 49 Primary Health Care Organisations (PHCOs) across Australia is not the question, since the number should be determined as a consequence of enagement of local populations to meet local needs. As quoted by AGPN CEO David Butt who said the final number of PHCOs would be the product of careful consultation with divisions on regional need.

“There is no right answer as to what the number should be,” Mr Butt said. “There are obviously different options... taking into account different criteria.”

http://www.medicalobserver.com.au/news/agpn-maps-future-of-49-divisions

"Such PHCO combinations as “Inner Western Sydney & Canterbury Bankstown” covering huge areas of Sydney with massive populations (Ashfield, Bankstown, Burwood, Canada Bay, Canterbury, Leichhardt, Marrickville, Strathfield and part Sydney with a project population by 2021 of 763,164 people) are expected to be unmanageable, and doomed to repeat the current ‘downsizing’ exercise from NSW Health re: super-sized Area Health Services being regionalised so they can respond more effectively to local needs.

Specific comments on the Carla Canny & Associates report (where relevant)

"Amongst government announcements in the lead up to the election, there have been two public discussion papers that have proposed options for redrawing health care boundaries in the Bankstown and Fairfield –Liverpool areas:

1. Permanent dissolution of the Bankstown, Fairfield, and Liverpool Divisions into a Campbelltown-based Macarthur -Southern Highlands PHCO. This option was outlined in the document titled “Discussion Paper on Implementing the National Health Reform in NSW” (NSW Health August 2010). Under this option, Bankstown GP Division would be forced into amalgamation with Fairfield-Liverpool under an expansion of the current Macarthur -Southern Highlands Divisions, to which there is considerable local GP resistance.

2. Permanent dissolution of Bankstown into a Central Sydney PHCO, based on the current Central Sydney Division. This option was outlined in the document titled “Framework for development of Primary Health Care Organisations in Australia” (Carla Cranny and Associates May 2010). Also under this option, Fairfield-Liverpool would become the northern margin of a giant Macarthur -Southern Highlands PHCO, to which there is considerable local GP resistance.

"These two documents made different recommendations, and have created significant confusion in south west Sydney.

"Further, under both scenarios 1 and 2 there is a significant risk that the local influence on primary health care decisions will be lost across much of south west Sydney. Health professionals in Bankstown, Fairfield and Liverpool may be inappropriately (& permanently) relegated to the periphery of decisions made in central Sydney or Campbelltown, under options proposed by Carla Cranny and Associates, and NSW Health. That is, health professionals and communities in some of the most complex and disadvantaged urban LGAs in Australia, will effectively be silenced, and permanently disengaged unless the Bankstown-Fairfield-Liverpool alliance is allowed to develop.

Comments on Local Hospital Networks

"NSW Health has determined it will be using the term “Local Health Networks” (not Local Hospital Networks), apparently as it has a large stake in community health services which may not be part of the Commonwealth health reform process. This is potentially a disaster for PHCOs in NSW unless service-provider agreements are created between the LHN and the PHCO. The Commonwealth should determine through COAG the process for developing policy that binds Commonwealth & States/Territories to the health reform agenda, so that every jurisdiction is able to progress with these National reforms.

"An example of such PHCO-LHN collaboration policy would be the requirement to have at least 1 (but not more than 2 for example) cross-Board memberships of these two entities. Currently it is unclear what the LHN/PHCO clinical and administrative governance practices will be and to whom such issues as complaints will be referred."

Does not this submission make one wish that Dr Susan Harnett was the Chair of the Southern Highlands Division of General Practice? At least she had something to say before the shotgun marriage took place. Our Division seems to have lost its voice!

SSWAHS and the local Division of General Practice.

Welcome to the Southern Highlands Division of General Practice

"Southern Highlands Division of General Practice (SHDGP) is a federally funded not for profit organisation which assists general practitioners and the (SSWAHS) Health Service to deliver health services to people in the Southern Highlands."

In its most recent "Highlands Doctor" newsletter their Chair makes the following comments about the proposed changes in health services generally, and especially community and primary health care. He writes of the "Primary Health Care Organisations" proposed by the federal government.

"What are PHCOs?

The Government has determined that these are best formed from the Divisions – or GP Networks, as they are often now known.

Over the past dozen years, the Divisions have shown that they can unite GPs into public health co-ordination and delivery roles, and gradually change the health culture from a hospital bed based one to one more focused on primary care.

They have successfully been fundholders – for example, in Better Outcomes in Mental Health (BOMH) and More Allied Health Services (MAHS - which has funded our Diabetes program).

The Divisions were the natural contenders to run the PHCOs – though there are a number of other organisations (eg health funds and other “for profit” health companies) which are keen to do the job if GP Divisions are not.

It seems to me that Divisions are best suited for these expanded roles.

However, the Government does not wish to deal with a cumbersome number of small PHCOs – there are 110+ Divisions across Australia currently – so it has indicated that it wishes Divisions to seek partners and amalgamate to form PHCOs to serve a population of about 600,000 people.

This means that our Division, serving just 45,000 to 50,000 people, would not be big enough to form a PHCO in our own right. We will now be talking to our neighbouring Divisions to find the partner that has the most commonality in purpose, philosophies, service delivery etc.

All this has to also be examined in the light of the changes in boundaries to the area health services (Sydney South West Area Heath Service is likely to be divided into two or three smaller areas under the Federal proposals).

As we find out more details of the roles that we will be expected to play in the remodelled heath system, we need to identify all the best features of our Division and make sure we maintain these benefits to our doctors, our practices and our patients as we move into these new reforms.

It is heartening to see that the Government has recognised the pressing need for infrastructure funding for general practices - though most GPs feel that 20+ more “super clinics” (what a dismal name – almost as bad as “Medicare Local”?) and 400+ general practice infrastructure grants is just scratching the surface.

If we are going to be working with more practice nurses, allied health workers and co-located with other primary health services (eg Primary Health Nurses), we need more rooms.

And we have a growing number of registrars (20% increase in the number of registrars in our local City Coast Country Training (CCCT) organisation for 2011, for example), medical students, PGPPP junior doctors – as well as practice nurse and general nursing trainees seeking experience within GP walls. Again, all need room and/or rooms!

Our Division will keep you posted as we work our way through these new reforms. We enjoy a reputation already among Federal and State heath administrators as an innovative, “can do” Division, and I am confident that our experience as Division over the past 16 years will stand us in good stead to take a lead role as we transition into a PHCO.

It is a great opportunity to work out how we can do things better, and with the anticipated funding, make this actually happen.

Vince Roche

His comments are followed by those of the Division's Executive Officer. Noticeably in his text there is a sense of contrast to the opening statement of the Southern Highlands Division being a "federally funded not-for-profit organisation which assists general practitioners and the (SSWAHS) Health Service to deliver health services to people in the Southern Highlands."

There are two things in his text which stand out for old Socrates: one is the vision that he has of this being a great opportunity for his Division and others to grab a large part of the pot of taxpayers money to satisfy his vision of an Empire in the south. The second stand-out feature is the total absence of how the Divisional Executive in general, and its Executive Officer in particular sees how this windfall is going to be helpful to the "people in the Southern Highlands".

Call old Socrates a bit of a windbag - but can anyone else see the words - "patients" or "people" in the writings of either of these other windbags? All Socrates can see is a couple of old cronies backslapping each other for managing to extract a lot on money out of current and previous governments for their own plans, staff and programs.

Primary Health Care Organisations (PHCOs):

These are now being called ‘Medicare Locals’ by the Government – apparently reflecting a move away from ‘Primary’ given the pending legal action surrounding that title.

This new name is being resisted by AGPN and the Divisions and, in company with many others, we are continuing to use the term PHCO.

Boundaries for the sixty or so PHCOs, to which the existing 111 GP Divisions will be reduced, are to be agreed between the Commonwealth and the States by December 2010. This will have regard to the boundaries of the new Hospital Networks.

In the case of the SSWAHS Hospitals, it is possible that we will know the network boundaries as soon as late this year. However the current betting seems to be favouring a two way split, with our network including Liverpool Hospital.

Key strategies for PHCOs will move away from predominantly individual clinician based membership, with activity and governance to be more reflective of wider community based health care providers.

GPs are to remain the cornerstone in the overarching governance structure. Amongst other things, PHCOs will have responsibility for after hours services; strategic planning and development; workforce issues; and population health.

We understand that PHCOs are to cover populations of up to 600,000 people and therefore one thing is certain in our case. That is, we are too small to be able to constitute a PHCO. Indeed, the AGPN has just released the Cranny Report into the suggested PHCO boundaries which has us amalgamated with Macarthur Division.

To this end, we have commenced negotiations with Macarthur Division to, amongst other things, ensure that we retain our rural status and activities and our local management. However, there are still hurdles to cross, including that, while the Government acknowledges the Cranny Report, at the end of the day, PHCOs have to relate to the future Hospital Networks as agreed with the States.

This is to be agreed by December of this year under the COAG agreement. According to the Government’s handouts, the first round of 14 or 15 PHCOs are to be in place by July 2011 with the remainder by July 2012.

We are collaborating with Macarthur Division to go all out to be in the first round, since waiting until the later date will carry the danger of a longer period of instability. There will be dedicated transition funding over and above the normal Division funding which will provide for our existing Division services in the meantime and during the transition period.

Other measures flowing from the Commonwealth Budget which are worth repeating include a national EHealth System to be in place over the next two years; more GPs; 23 new Super Clinics and work on 425 existing practice premises to allow team based care; the Practice Nurse Program; paid training for PNs; better support for RACF nurses; more mental health nurses; more mental health programs; and the new Diabetes program.

It is noteworthy that PHCOs in various forms now exist in New Zealand, Canada, the UK and the US. It is expected that there will be a Canberra-based central PHCO as well as State branches. Some in the network are favouring the retaining of existing Divisions, with the Division becoming a part of the PHCO. However this seems unlikely.

Lastly, any Division that doesn’t move into the PHCO model will not be funded beyond 2012. Perhaps most importantly of all for GPs, the PHCOs will not control individual GP practice matters.

Warwick Ruscoe

Now call Socrates a bit of a simpleton but I seem to recall that this last author was most outraged that he was overlooked in a pre-selection ballot for a nice safe Liberal seat. A second rebuff was his failed attempt to have the Wingecarribee Council approve his grand plan to build a "super clinic" (funded by the federal government, of course) over the public car park in Moss Vale which, only coincidentally (of course), happens to be right next to the Moss Vale GP practice owned by the Chairman of the Division.

Even more alarming is the unholy alliance with SSWAHS looks as though it is going to be the preferred option for the Southern Highlands Division if the prediction from the Executive Officer is correct about the links with Liverpool Hospital, the Imperial home of the SSWAHS Executive.

Perhaps the Southern Highlanders should be asked by the State and Federal Health Ministers whether we want more of the same treatment that has been dished out to us by Liverpool and SSWAHS.