The previous Croakey post put out a call for suggestions about how Medicare Locals might engage their communities in setting directions and priorities.
Professor Helen Keleher, President of the Public Health Association of Australia, has responded with a strong call for some “bigger picture” action that goes way beyond the remit of Medicare Locals. Primary health care and population health need to combine forces and create broad partnerships to address to some of the underlying determinants of health, she argues.
Helen Keleher writes:
About 10 years ago, the story goes, the Department of Health and Ageing hosted a visit from Professor Michael Marmot (now Professor Sir MM) who has headed up a number of large, influential studies and most recently, was the Chair of the World Health Organization Commission on the Social Determinants of Health (CSDH).
During his visit to Canberra, he spoke at length to an audience of staff from across DoHA about the widening gap between those whose health is good and those whose health is poor, the correlations between health and socio-economic status and the imperatives of addressing health disadvantage. He has often made the case, as he did in Canberra that day, that health is created outside the health sector but that the health sector must take leadership in social health initiatives to tackle poor health.
The audience had an opportunity to ask questions, but there was silence until one young man raised his hand and said ‘Professor Marmot, what do you think we can do about it? All we do in the Department is manage contracts for hospitals’. There was silence until Professor Marmot responded, saying quietly, ‘well, you are the Department of Health – if not you, then who?’
Fast forward to 2010 into our current environment of health reform. The differences between social groups in Australia are stark and can no longer be ignored by the health system.
Government is proposing to reform primary care into primary health care in organisations called ‘Medicare Locals’. These will broadly stamped be onto existing Divisions of General Practice ostensibly because the government wishes to deliver improved after-hours primary care services and further strengthen general practice – both are laudable goals.
But they won’t fix entrenched health and social inequities because Medicare is about episodes of care for people who are already unwell or in poor health. Certainly Divisions have been involved in the rollout of population programs such as vaccination and some screening for high-risk individuals but what we really need is a much broader approach to the health of whole populations.
We need comprehensive primary health care as well as population health planning. They go hand-in-hand and if developed properly by the current government, would be a significant achievement – and deliver on a really big idea that is entirely do-able but also absolutely necessary if we are to turn the tide of chronic and communicable diseases and endemic levels of poor health and social conditions. This is a bigger vision than just ‘reaching the unreached’ in primary care.
We have to connect the dots between poor health, social inclusion, poverty, life-styles and prevention/health promotion, and join the dots between early childhood services, housing, food insecurity, literacy and primary health care for example.
Primary health care is a broad based approach to health care that includes not only clinical care (doctors, nurses, allied health), but also prevention programs for individuals and whole populations, health promotion and community development, rehabilitation, public health measures and advocacy. But even a good, true primary health care is not sufficient – we also need to plan in broad partnerships for how each catchment will work to improve the health of its populations, and address the determinants of health and illness.
The primary determinants of disease are socio-economic, cultural and environmental, therefore the remedies must also include those determinants. To paraphrase Marmot, the determinants of individual differences in risk are different to the determinants of differences between social groups. Therefore, we must ‘lift our eyes from the individual in front of us to observe that there are patterns of disease in populations’ but tackling such patterns requires planning between a wide range of agencies who have a role to play in creating good health in families, communities, and regions. The approach to this is called population health planning.
The questions become not about why some individuals are more at risk than others but are rephrased as population questions: what is it about our society that causes so many of our young people to abuse alcohol, or carry knives, or take up smoking? What is it in our environment that creates the conditions in which Type 2 diabetes is endemic or why do so many people run out of money for food to feed their children? Why has problem gambling become such a huge problem? What can we do in our catchment, at local levels, to change those conditions?
Can Medicare Locals lead this work? No, it is not likely.
That is because Medicare Locals are looking like revamped primary care organisations – they do not give out a promise of true primary health care, but even if they were to be renamed and reworked as Primary Health Care Organisations, we also need them to be mandated to work in partnerships with other organisations and stakeholders on population health planning. In some regions, this kind of planning is being spearheaded by concerned service providers, NGOs, and local and state governments who see the need to work more strategically – their leadership demonstrates that it is a combination of primary health care and population health planning that is the way of the future and it is where reforms to the health system should be heading.
It is time for the health system to take leadership, recognize the drivers for health lie outside the health system and work in cross-sector partnerships to really drive change.