Thanks to the Parliamentary Library’s blog, FlagPost, for allowing this cross-posting. Amongst other things, it raises yet more questions about Medicare Locals, including the fundamental issue of what the Government means by “primary health care”.
Rebecca de Boer writes:
The Government has released the guidelines for the establishment and initial operation of Medicare Locals (MLs) following the consultations around its discussion paper on the governance framework. Applications are invited for the operation of MLs to commence in either mid 2011 or January 2012. Approximately 15 MLs will be awarded in each round. The guidelines and prior ministerial statements would indicate that the initial groups of MLs are likely to be drawn from existing Divisions of General Practice.
The overarching objective of MLs is to ‘coordinate primary health care delivery to address local needs and service gaps’. The guidelines set out the functions of MLs, including the expectations of the Government, according to the following ‘strategic objectives’:
- Improve the patient journey through developing integrated and coordinated services
- Provide support to clinicians and service providers to improve patient care
- Identification of the health needs of local areas and development of locally focussed and responsive services
- Facilitation on the implementation and successful performance of primary health care initiatives and programs
- Be efficient and accountable with strong governance and effective management.
Commentators have highlighted the gaps in the guidelines: namely the absence of any mention about the social determinants of health, ownership and governance arrangements and how MLs will balance competing objectives in the delivery of primary care.
Beyond what has already been canvassed, there are some key issues that are not addressed by the guidelines.
Firstly, ‘primary health care’ is not defined, perhaps reflecting that there is not yet agreement between the States and the Commonwealth on what constitutes primary health care.
As a corollary to this, there is no reference in the guidelines to the primary health care services currently provided by state and local governments (or other relevant state funded services such as housing) and what the integration with MLs might be. Specific areas integral to effective primary health care such as mental health services, aged care, Indigenous health, culturally and linguistically diverse programs/services and disability services are also not mentioned in the documents.
With the publishing of the guidelines there will now be a number of questions that turn to the detail of how MLs will operate:
- What outputs or outcomes are MLs expected to deliver and how their performance will be evaluated? The Minister for Health has recently introduced the legislation to establish the National Performance Authority (NPA). The Second Reading Speech notes that the NPA will ‘collect, analyse and interpret’ information and report on Healthy Communities (structured around MLs). It would appear that the NPA will play a major role in the evaluation of MLs, particularly in relation to statistical information. It is not clear whether consumers and primary health care provides will have an active role in the evaluation of MLs. As noted in the guidelines, the performance framework for MLs is still being developed by the Commonwealth but MLs are expected to provide a series of reports to the Commonwealth about financial information and reporting against program objectives and outcomes on a regular basis. A challenge for government will be to ensure that the various reporting requirements do not overlap and create a significant administrative burden for MLs. A greater challenge will be to ensure that the performance framework has the appropriate measures and tools to effectively monitor, and evaluate, the performance of MLs.
- Among other expectations, MLs are expected to ‘improve the planning of primary health care services to respond to local needs’ and ‘support the development of e-health and health information’. Will the budget of $477 million over four years for approximately 57 MLs (as noted in Senate Estimates on 23 February 2011), which is around eight million dollars per MLs over four years, be adequate to meet these expectations?
- Will MLs be sufficiently empowered to engage in the planning that will be required to deliver on these expectations? Planning for primary health care services has traditionally been the domain of the States and it not clear if this role will continue under the Heads of Agreement – National Health Reform signed by COAG in February 2011. Access to adequate data and high-level expertise required for planning may be an issue for MLs. The COAG Reform Council has already highlighted lack of information about primary care services in its Baseline Performance Report on the National Healthcare Agreement (2008-09). It notes that there are no measures of the adequacy of access to primary health care or whether the availability of primary health care services is meeting need. MLs are being expected to maintain a population health database but it not clear from the guidelines what role they will play in the development of this database or if this information will be provided by the Commonwealth.
- What role might MLs have in the Government’s ehealth agenda? There have been significant delays in the implementation of the Government’s ehealth agenda, some of which have been attributed to multiple funding streams and jurisdictions. The Government has recently announced funding to a small number of Divisions of General Practices (on which the MLs are initially expected to be based) for ‘Lead Implementation Sites’ of ehealth projects undertaken by the National E-Health Transition Authority. This approach may continue under the proposed ML structure.
MLs are expected to ‘provide more integrated care’ and ‘ensure more responsive local GP and primary health care services’. These examples point to the importance of the interface between MLs and the Commonwealth and MLs and the States if they are to achieve their objectives. Integration at the local level is also likely to be critical. The goodwill of external organisations and individuals, over which the ML has little or no control, and the availability of incentives to encourage organisations to participate in the MLs will be important.
Although the first group of MLs are likely to be drawn from ‘high functioning’ Divisions of General Practice, many of which have had experience in negotiating some of these issues, as MLs their role is much broader.
To fulfil the Government’s long term objective for MLs to provide a ‘coordinated package of care’ and act as fund holders for primary care, an agreed definition of what constitutes primary health care and sufficient empowerment of MLs would seem to be necessary pre-requisites.
***
Previous Croakey posts on Medicare Locals
• How will they work?
• Reaction: We need a broader focus
• Some challenging questions for Medicare Locals
• A mega-wrap of analysis
• Hospital chief says Medicare Locals must focus beyond health services
• What will we learn from the Medicare Locals tender documents?
Some may wish to browse a blog on the e-Health aspects of MLs.
If so go here:
http://aushealthit.blogspot.com/2011/03/medicare-locals-i-really-wish-someone.html
Cheers
David.
Medicare Locals will not break the stalemate surrounding health reform. They will, however, provide a focus for enterprising initiatives from consumers that lead in the direction of genuine consumer-centred health care.
For example: consumers who want integrated care and self-direction will be able to say to a Medicare Local: “I want a package of money from several of your funded programs that is made available to me for integration of my supports and care, in the form of a personal budget as is now accepted in disability.”
Medicare Locals that are innovative will have the capacity to do this, and can learn from any number of disability agencies, and increasingly aged care agencies, who now do it. Mamre Association in Brisbane is one of the best, and has been using funded programs to offer family-managed self-directed services in disability for 20 years. Families use the money to purchase the care they want, and employ the care workers they need, directly.
The systems for self-management of packages are now available, along with easy to use self-management tools.
The stalemate in health reform will be broken only when innovative organisations, and enterprising consumers, start exercising some intregrated person-centred controls over arrangements that are actually within their power to control. Without this kind of innovation, the rhetoric about integrated care will go on for decades without anything changing on the ground for the consumer.
This is a major paradigm shift in health, away from the statist approach of looking to government to deliver what everyone wants, and towards an empowerment and enterprise approach that follows the self-direction and individualised funding approach in disability. Chronic illness, aged care and mental illness can easily follow this direction, but the consumer leadership has not been here in these areas as it has in disability. Hence the delay in general health.
This approach will be explored at a workshop on consumer-centred health care on March 21/22 http://www.partnerships.org.au/
Vern Hughes
vern@partnerships.org.au