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.
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
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
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.
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. “
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.
https://croakey.org/a-comprehensive-analysis-of-the-plans-for-medicare-locals/