Uncertainty in health care is generally not much fun. Tests results that are not definitive, treatments that may or may not work, nasty side effects that may or may not occur…
Uncertainty in health care reform is similarly vexing. Would an Abbott Government put aside all the work of the past few years? Would an elected PM Gillard push ahead with the reforms associated so strongly with “health minister” Rudd? Even if the reforms do go ahead as planned, there are so many uncertainties around the implementation. As one over-worked health manager commented to Croakey recently: “At the moment, a lot of it is a guessing game as there is little detail.”
The Government’s plans for transforming the care of diabetes by introducing voluntary patient enrolment and capitation payments have been causing concerns in some quarters.
A new advisory committee has been appointed to address some of the implementation kinks of this plan. It includes diabetes and consumer experts, and the former chair of the National Health and Hospitals Reform Commission, Dr Christine Bennett. The AMA is MIA, and no doubt we shall be hearing plenty more about this from Dr Andrew Pesce et al.
Meanwhile, the current issue of the Medical Journal of Australia focuses on general practice and has a number of timely articles for those with an interest in health reform.
Will the new diabetes measure make a real difference?
Professor Doris Young, Dr Anthony Scott and Professor James Best, from Melbourne University, have raised several concerns in their article, For love or money? Changing the way GPs are paid to provide diabetes care.
While patient registration has potential benefits, they suggest that “limiting registration to specific groups of patients is a piecemeal approach and inefficient”, and that “voluntary registration for all chronic diseases that require longitudinal care would seem a better way forward”.
They caution about the potential for “gaming and other unintended consequences” with capitation payments, and also highlight several areas where more detail about the program is needed. And, of course, there is the usual call for evaluation to be made a priority.
They say: “The most important question is whether the new scheme will be able to drive real behavioural change among primary care teams and patients, rather than being just another way of delivering funding to those already doing a good job.”
Gaps in the health reform agenda
More questions about the diabetes program come from Professor Michael Kidd, Executive Dean, Faculty of Health Sciences, Flinders University, a past president of the Royal Australian College of General Practitioners, current chair of Doctors for the Environment Australia, and president-elect of the World Organization of Family Doctors.
He writes: “The program risks encouraging perverse incentives to enrol people with mild diabetes and to avoid enrolling those with complex care needs. It remains unclear how the program will support improvements in the care of all people with chronic disease and the implications for the many people with diabetes who have comorbid chronic health problems.”
While the plans for primary health care organisations (PHCOs) are welcome, Kidd says there is “scant detail” on how the transition to PHCOs will occur and how the talents and commitment of the thousands of people working in Divisions will be retained. It is also unclear how PHCOs will link with each of the new local hospital networks and how these two separate regional entities will complement each other instead of simply expanding the “blame game”.
Kidd says PHCOs will also face the challenge of diminished GP ownership, while bringing together the diverse cultures of the many facets of community-based health care delivery.
He also highlights the relative neglect in the reform package of aged care, mental health, dental health, preventive health, e-health, and the social determinants of health, as well as of Aboriginal and Torres Strait Islanders and rural and remote health.
Furthermore, “None of the announcements addressed the impact of climate change on human health, despite the World Health Organization Director-General stating that this is “one of the greatest challenges of our time”.
For Croakey’s money, Kidd is right on the mark with this comment:
“Is this all real reform or a series of loosely connected new programs and initiatives that aim to produce improvements in discrete aspects of our complex health care system, but which risk a continuation of the problems of cost shifting and blame shifting?
“There is a risk that the announced initiatives, while providing significant increases in funding for some aspects of primary care, may not result in a fundamental shift from a system focused on hospitals and disease to a system that focuses on community-based care, health promotion and the prevention of illness.”
Meanwhile, the journal’s editor Dr Martin Van Der Weyden questions the wisdom of imposing more reforms on GPs who “are already experiencing difficulties meeting the constant and ever-changing demands placed on their practices”.
He says that reform is generally more readily acceptable if it:
- lessens rather than increases the workload;
- improves the efficiency and effectiveness of tasks;
- increases the quality and safety of services; and
- provides tangible incentives for participants.
Van Der Weyden also questions whether the investment in e-health is likely to yield tangible returns, and reminds us that the Opposition Leader Tony Abbott, in a former incarnation as health minister, was responsible in 2005 for pulling the plug on HealthConnect — a national system of e-health records that could be shared over secure networks with strict privacy and consent controls.
Van Der Weyden also says that since its inception in July 2005, NEHTA has been spending just under $164 000 a day, but is yet to deliver any e-health outcomes beyond a 2009–2012 strategic plan and the development of a national health care identifier system that was recently ratified by the Australian Government. He also calcluates that over two years, NEHTA will spend $639 315 each day on the implementation of personally controlled electronic health records.
Whither divisions of general practice?
Much of the health reform debate has assumed that divisions of general practice will evolve into Medicare Locals. However, Professor Philip Davies, of the University of Queensland, suggests there are other options for divisions, including
- Taking an ownership stake in an ML.
- Becoming providers of services to one or more MLs.
- Delivering ML services under contract.
He says Divisions will only be able to transform into Medicare Locals if they are willing to make significant changes to their ownership and governance arrangements. They will become new organisations that bear scant resemblance to Divisions as they are currently known, and GP engagement will, inevitably, be reduced.
The other options may enable them to retain many of their existing characteristics, albeit, in some cases, with the likelihood of reduced funding from government.
Davies says some divisions may not wish to be part of Medicare Locals, for example, if they wish to retain existing ownership and governance arrangements, have an ideological dislike for or distrust of the ML concept, or are unwilling to merge with one or more nearby Divisions to form a body of sufficient size to become an ML, or are unsuccessful in their bid to fulfil the ML role in the face of competition from other Divisions.
Davies also raises some interesting questions around the governance of Medicare Locals.
He says: “The theme of accountability to local communities runs strongly through the rhetoric surrounding MLs, and this will have implications for their ownership. Divisions are currently companies that are owned by their members. The Australian Institute of Company Directors’ Code of Conduct explains that a Director’s “primary responsibility is to the company as a whole”. That means, when the chips are down, Division Directors are expected to put their members’ interests first. If ML members were to be “primary health care providers or provider organisations” as the AGPN blueprint suggests is a possibility, where would that leave consumers’ and communities’ interests?”
Davies also says that recent analysis of the evolution of primary care organisations in New Zealand and England offers some salutary insights. In both countries, the benefits of clinical involvement appear to have been put at risk by developments that resulted in primary care organisations becoming “unduly bureaucratic, managerially controlled, or perceived as belonging to the wider health system rather than local clinicians”.
He adds that divisions that choose to become MLs will undoubtedly become more firmly embedded in the machinery of government and may thus risk losing some of the benefits of clinical involvement. Divisions that seek to retain current levels of clinical involvement may find that other pathways prove more attractive, he adds.
State of play in NSW
NSW Health plans to have a discussion paper on local hospital networks available by the end of this month or early August, says the D-G, Deb Picone.
Key issues raised in a series of consultations in NSW include:
- Preservation of clinical networks
- Importance of a population health focus
- Relationship with Medicare Locals
- Transport and distance
- Self sufficiency
- Economies of scale
A lot of talk, a lot of work…but will it all end up going anywhere? For NSW, the uncertainty won’t end on August 21. A new state government is bound to mean yet more restructuring…I wonder what will happen to Deb Picone’s blog then?
Update: Andrew Pesce’s speech to the National Press Club today, which ends on what you’d have to call bi-partisan political sloganeering: “We need real action to move forward. To move forward, we need real action.”
And here you can download the AMA’s election health policy platform, released today.
And here is the Q and A session at the press club.