To mark the first anniversary of the Australian Medicare Local Alliance (AML Alliance), Croakey contributors were asked to suggest questions they’d like answered about the organisation and the country’s 61 Medicare Locals more broadly.
Their questions broadly fell into six categories:
• Where is the value?
• What about Indigenous health?
• Governance and resourcing issues
• What about population health?
• Some rural health concerns
• What about mental health?
At the very bottom of the post are some pertinent questions that journalists might like to investigate further….
Many thanks to the AML Alliance and CEO Claire Austin (pictured) for taking the time to answer the questions. It was no small effort!
1. Where is the value?
Q: What do you think Medicare Locals have done – or are on track to do – that would make governments want to continue supporting them?
Claire Austin: Medicare Locals (MLs) are improving population health outcomes, increasing system efficiencies, reducing costs, and structuring a sustainable system to meet the challenges that an ageing population and chronic disease burden will bring to it in the future. Specific examples of what MLs are doing include:
Taking pressure off the hospital system
MLs are reducing avoidable hospital admissions and presentations. They are doing this by driving and coordinating a prevention and health promotion approach locally, such as through: consumer health literacy programs, consumer health education campaigns (e.g. smoking obesity, alcohol), health professional education and training, promoting and supporting patient self-management, developing, disseminating and supporting evidence-based treatment regimens, partnering with local stakeholders to help address the social determinants of health.
Increasing equity of access to services – especially for disadvantaged and marginalised groups
MLs are improving access by taking a population health approach to care. Looking beyond the individual-focused medical model of care, MLs conduct population health needs assessments to identify local service gaps, health inequalities and service inefficiencies. They then partner with local stakeholders to connect care, fill gaps and ensure equal access to care for all Australians. They are doing this in a number of ways such as through creating innovative service and workforce models, recruiting, supporting and up-skilling the health workforce, commissioning services, and in cases where there is identified market failure, directly delivering services. This work is particularly pertinent in rural and remote communities where MLs are already beginning to address workforce shortages and maldistribution.
Helping to Close the Gap between Indigenous and non-Indigenous Australians
MLs are helping to close the gap by working in partnership with Aboriginal and Torres Strait Islander communities and organisations – such as the Aboriginal Medical Services and Aboriginal Community Controlled Health Organisation sectors – to design and deliver Indigenous health programs and services. Examples of this include employing Indigenous health outreach workers and project officers to directly provide services to Indigenous communities (including in remote areas through outreach services), providing cultural awareness training and support to mainstream primary health care services, encouraging self-identification, and helping to address the social determinants of health that disproportionately affect Indigenous Australians.
Helping to improve the mental health of Australians
MLs are coordinating, commissioning or directly delivering key mental health services and programs. This includes Access to Allied Psychological Services (ATAPS), the headspace youth mental health initiative, and the recently established Partners in Recovery program which will assist those Australians with severe and persistent mental health conditions by taking a holistic, integrated approach to care.
Overall, MLs are helping to address Australia’s most pressing health priorities, and they are doing so whilst promoting system efficiencies, reducing health care costs, promoting equality, improving safety and quality, empowering local communities and providing greater transparency and accountability to the system, consistent with bipartisan policy.
MLs were developed on the back of a strong evidence-base to come out of the National Health and Hospitals Reform Commission review; winding them back or impeding their work would contradict evidence-based policy and result in a return to the status quo – the unacceptability and unsustainability of which is well accepted.
Q: What 3 specific achievements would you promote to a new health minister to sell the value of MLs?
• Reducing avoidable hospital admissions and presentations
See response to question one.
• Reducing duplication
MLs are working with local stakeholders and service providers to conduct population health needs assessments which in addition to identifying gaps and market failures, also identifies service duplications and system inefficiencies. The subsequent development of their population health plans then works to fill those gaps and minimise duplication resulting in less waste and more resources available to be invested back into the community.
• Connecting primary and acute care
A recent ML survey indicated that more than 70% of MLs are currently working with their Local Hospital Networks to jointly deliver on a variety of initiatives, such as in the areas of hospital avoidance, discharge, referral and follow-up, medication management, data sharing, direct program delivery (e.g. Indigenous chronic disease coordination), and population needs assessment and planning. The results of which include reduced hospital admissions and presentations, better care coordination and continuity, reduced events of medication misadventure, and the more efficient use of resources.
Q: How do you explain what Medicare Locals are for?
Claire Austin: MLs have been established to coordinate local primary health care services in response to local need.
They address service gaps, duplications and inefficiencies, and ensure local communities have access to the right care in a timely manner.
They also lead on a broader health system change that shifts the focus from episodic hospital care to comprehensive primary health care. In effect, working towards keeping people well and out of hospital.
This involves a stronger emphasis on population health, prevention and health promotion, equity and responding to the social determinants of health.
MLs help create an effective and sustainable health system that will continue to meet the needs of all Australians long into the future.
Q: The coalition has been pretty sceptical about the achievements and potential of Medicare Locals. How would you go about countering those views?
Claire Austin: The Coalition knows that Australia’s health care expenditure is unsustainable. It is also aware that excessive and inappropriate use of the hospital system is what is driving this cost burden. The Coalition appreciates that stronger primary health care is the best way to alleviate the burden, and it acknowledges that primary health care must be well-coordinated and supported if it is to achieve this. The Coalition support coordination role, which is exactly the role of MLs.
Evidence from the National Health and Hospitals Reform Commission review clearly tells us that primary health care organisations set up in the way MLs are is the most effective and efficient means of achieving these ends.
With regard to any scepticism, the work and achievements of MLs speak for themselves. Many Parliamentarians who have so far visited MLs have noted their appreciation for their work and noted the gains they are making.
We encourage all parliamentarians to visit their local MLs and see how much their local communities value them. Furthermore, we welcome engagement from all sides of parliament to engage with us and the broader health care sector to understand and explore opportunities to improve the primary health care system.
Q: What’s your response to the assertion that MLs are just adding another layer of bureaucracy to the health sector?
Claire Austin: The sector-wide ML survey indicated that 73% of ML FTE staff are working at the frontline – in programs (53%), care coordination (16%) and community-based health promotion (4%).
Only 26% have been identified as administrative personnel.
MLs have also reported spending the equivalent of three months of staff time over a 12-month period meeting Department of Health and Ageing reporting requirements. MLs are not the bureaucracy; the bureaucracy is being imposed on them. AML Alliance is advocating to Government, on behalf of MLs, to reduce this burden.
Furthermore, MLs are reducing the bureaucracy by putting local health resources and decisions into the hands of local organisations, governed by local community members, not Commonwealth bureaucrats.
Q: What measures of success are driving the work of the MLs?
Claire Austin: While improved population health outcomes, system efficiencies and cost savings are some of the overarching objectives driving MLs, these can be difficult to measure and to subsequently attribute to one organisation – or even one sector.
MLs may therefore measure success through proxy indicators known to contribute to these objectives – at least in the short to medium term. For example, strong and effective partnerships with other organisations and relevant stakeholders – e.g. to connect care and share resources; the consistent use of practice support systems, such as the Personally Controlled Electronic Health Record (PCEHR), Secure Messaging and population health planning tools; local service accessibility; and general community engagement and satisfaction.
Q: What will Australia look like in 5 years if they are successful?
Claire Austin: If MLs are supported with the necessary resources and appropriate flexibility as independent organisation, Australia can expect to have:
• A better coordinated, integrated and appropriately linked health care system, particularly between acute and PHC but also closely linked to and actively working with the social sector
• A more community based and focused health care system incorporating health promotion and disease prevention as a key focus of thinking and action
• A healthier community as measured by increased life expectancy, quality of life and general health literacy
• A health system able to monitor and rapidly assess areas of need and identify gaps requiring attention
• A healthier and more socially included older population
• A healthier and more socially included disabled population
• A healthier and more resilient younger population
• A reduction in the social gradient impacting on Australia’s health and wellbeing
• Good progress in reducing the life expectancy and disadvantage gaps between Indigenous and non-Indigenous Australians.
Q: What do you see as the 10 or 20 year vision for MLs?
Claire Austin: Achievements in the five year vision are maintained and enhanced
Q: How has the AML Alliance added value during its first year?
Medicare Local programs and performance development
• Helped MLs establish and consolidate their capacity and performance through providing resources, tools, workshops, one-on-one support and supporting peer sharing and learning (while also undertaking AML Alliance’s own operational establishment and development).
• Coordinated and supported national programs such as after-hours, ehealth, mental health, Indigenous health, immunisation and telehealth.
• Developed resources, workshops, webinars and other web-based education and training modules for MLs, including on ehealth, commissioning, after hours, population health planning, organisational development and human resources.
• Provided timely and pertinent information through network publications and regular media releases on topical health issues.
• Brought members together to share information and learning by delivering over 30 face-to-face network events for MLs and other stakeholders. These were useful in better informing and enhancing PHC delivery across a broad range of areas including ehealth, Indigenous health, practice nursing, telehealth, mental health, population health, corporate services and Human Resources, pain management and prevention.
• Delivered a successful AML Alliance National Primary Health Care (PHC) Conference attended by 983 delegates from a broad stakeholder base as well as hosted the World Health Care Networks (WHCN) Conference.
• Commenced national work in clinical engagement and cross sector collaboration including two successful national workshops.
• Established a knowledge hub forum to share information and resources in various areas including After Hours, Indigenous health, pain management and prevention, population health.
Strengthened and expanded stakeholder engagement
• Extended growth in partnerships and stakeholder engagement with key national health infrastructure such as the Australian National Preventative Health Agency (ANPHA), HealthDirect Australia, and the National Health Performance Authority (NHPA); as well as with other health and aged care sector groups such as Pain Australia, Australian Health and Hospitals Association (AHHA), and the National Aged Care Alliance (NACA).
• Held four inter-sectoral grand challenge sessions regarding health system integration and preventative care, working with a range of key agencies such as the Australian National Preventative Health Agency (ANPHA); the Australian Health and Hospitals Association (AHHA), beyond blue; the Australian Research Alliance for Children and Youth (ARACY), The Council of the Aged (COTA), and Catholic Health Australia (CHA).
• Continued and strengthened engagement with key general practice and PHC groups through active participation in United General Practice Australia (UGPA) and the National Primary Health Care Partnership (NPHCP)
• Established the AML Alliance General Practice Forum with membership from MLs to provide advice and exchange on issues affecting general practice.
Policy, advocacy and consultation
• Advocated on behalf of MLs to ensure flexible funding arrangements and made progress with the Department of Health and Ageing in streamlining ML reporting requirements.
• Developed a range of policy submissions and tenders supportive of health reform progress, including submissions on the social determinants of health and on the draft Commonwealth PHC strategic framework.
• Delivered a Federal Budget submission focused on value for money and preventative health care.
• Developed a joint position statement and conducted of a joint event with ANPHA to share and showcase ML examples of prevention in action.
• Ensured evidence-based policy and program development through ongoing collaboration with the Australian Primary Health Care Research Institute (APHCRI), and international collaboration through the World Health Care Networks (WHCN) movement.
• Began establishing an NHMRC Partnership Centre for Better Health in partnership with APHCRI (ongoing).
• Ensured ongoing consultation with sector members, including through specially convened policy, project and program advisory groups, development of the General Practice Forum, execution of two Network Chairs and Executive meetings.
• Completion of a national Compact which sets out an agreed way of working between AML Alliance and MLs as well as between MLs themselves.
Q: With such a fuzzy understanding generally of primary health care and how it differs from primary care, how can we understand the PHC functions of MLs, and evaluate them?
Claire Austin: MLs are cognisant of the distinction between primary care and primary health care. They are aware of their responsibility to build and maintain a strong primary care system – one that supports and encourages multidisciplinary clinical team care, led by the GP who is the cornerstone of the primary care system. They are working with GPs, nurses and allied health providers to promote service integration and patient-centred care at this level.
They are also fully cognisant of the fact that primary care is only one sum of the equation which makes up the much broader and more complex primary health care (PHC) system.
Having the remit to work in and coordinate the PHC system is what separates MLs from divisions of general practice. Their commitment and ability to work under this broader remit is already evident in the population health approach they are taking to care. MLs are applying an equity and social determinants of health lens to their population health needs assessments and subsequent plans; the results of which are showing up in the partnerships they are forming and the services they are coordinating and/or providing.
Examples of this include:
• Bayside ML’s partnership with Victoria Police in which they work together to respond to, de-escalate and appropriately triage and refer mental health related cases that have prompted police attention;
• Barwon ML’s role in the G21 Region Alliance in Geelong Victoria which brings together sectors from across the region to work together on local issues ranging from arts and culture, to economic development, to health and wellbeing; and
• Northern Territory ML’s community garden projects that work to provide fresh fruit and vegetables to remote communities (many of which are Indigenous) by supporting locals to create, maintain and harvest their own produce – teaching people important vocational skills and building social capital and community resilience.
Communities and stakeholders can get a clearer understanding of MLs’ PHC functions by reviewing their population health needs assessments and plans, and through talking to providers, communities and MLs themselves about the work they are doing locally.
Q: How should the performance of MLs be measured?
Claire Austin: Presently DoHA has in place performance agreements with each ML.
Ultimately, MLs should be measured on their ability and performance in responding to local health needs. To do this well, as the ML sector evolves and matures, it is important for funders and regulators to collect data that is meaningful and fit for purpose. Thereby, we need to work together to build systems and processes to collect and collate data and evidence at the local level that demonstrates performance and informs future investment and action. Furthermore this needs to be meaningful and consistent to build a national picture of PHC delivery and performance.
Q: How can under-performing MLs be managed so that there is minimal adverse impact on services (and hence consumers)?
Claire Austin: AML Alliance is responsible for working with MLs to help identify any capability and capacity gaps and for assisting them to build capability to ensure high and consistent performance. AML Alliance has set up two functional areas within the organisation to assist with this – Member Services, and National Programs
Q: What are the implications of a change of government for MLs?
Claire Austin:Both AML Alliance and MLs’ direction is perfectly consistent with what we know of the Coalition’s policy. The Coalition understands that our hospital system is overburdened and too costly, and that coordinated primary health care has a role to play in alleviating this burden and reducing its associated costs.
Some Coalition MPs have visited a number of MLs and have noted the great job they are doing in terms of improving local health services and meeting the needs of their communities.
It is important to recognise that MLs are not part of the bureaucracy. They are independent organisations working within a complex environment to achieve the best health outcomes for their communities.
2. Questions around Indigenous health
Q: Aboriginal partnership – what structures does AMLA have in place to ensure national partnerships with Aboriginal community controlled health services (ACCHs)? How does this work and is there a formal alliance with NACCHO?
Claire Austin: The AML Alliance is working on a Letter of Agreement with NACCHO. This engagement is paramount to the primary health care sector and will be a key focus of the AML Alliance. The signals from both sides have been all about cooperation and partnership and it is definitely a space to watch in terms of progressive opportunities between the two agencies.
Q: Aboriginal accountability – how does AMLA show real accountability to Aboriginal and Torres Strait Islander people, with how they are providing effective services and use of Closing the Gap money? Is this on their website? Not inputs but programs and numbers of Aboriginal and Torres Strait Islander people accessing services?
Claire Austin: Data on the number of Aboriginal and Torres Strait Islander people accessing Closing the Gap services are provided to the funding bodies through regular reporting.
Details of the Closing the Gap programs coordinated by the AML Alliance are available on the AML Alliance website. Similarly, details of the Closing the Gap programs run locally by MLs are available on their respective websites.
It is imperative that we keep the dialogue flowing with other peak bodies like NACCHO and the Indigenous Health Leadership Group and respect the partnerships to maintain constructive progress in Indigenous health. That is what I want to see and I expect to see improvements in Indigenous health, now that an organised and systematic approach to primary health care, underpinned by culturally safe programs, is underway. Accountability is paramount but our accountability will be ultimately measured by the gains we can contribute towards closing the gap in life expectancy and disadvantage for Indigenous Australians.
Q: How many MLs have formal robust partnerships with Aboriginal and Torres Strait Islander ACCHS?
Claire Austin: Working with the Aboriginal Medical Services (AMS) and Aboriginal Community Controlled Health Services (ACCHS) sectors is paramount for MLs, and many have strong working partnerships in this regard – for example, the Aboriginal Medical Services Alliance Northern Territory (AMSANT) is a founding member and partner of the Northern Territory Medicare Local. AML Alliance and MLs are working with the Indigenous health sector to build on the gains made to date.
Q: Aboriginal investment – How many MLs are working in collaboration and subcontracting to ACCHSs to improve coordination and health outcomes? How are MLs deciding when this subcontracting is appropriate?
Claire Austin: MLs work in partnership with AMSs, ACCHSs and the broader Indigenous community to conduct their population health needs assessments and to subsequently develop local population health plans. These partnerships allow for the needs of Aboriginal and Torres Strait Islander peoples to be well defined and for the resulting services to be comprehensive and targeted in meeting those needs.
MLs subcontract health providers subject to that provider’s proven ability to most efficiently and effectively meet the needs of the Indigenous community. It is important to note that subcontracting is only a small way in which MLs engage Indigenous health providers. Genuine partnership (formal and informal) in the design, delivery and coordination of Aboriginal and Torres Strait Islander services proves a very effective means through which to best meet the health needs of Aboriginal and Torres Strait Islander people.
Q: What percentage of Aboriginal health outcomes is directly attributed to MLs?
Claire Austin: It is important for AML Alliance and MLs to be guided by Aboriginal and Torres Strait Islander health organisations and peoples as to what they consider are the appropriate measures for Aboriginal health outcomes. We are currently guided in this respect with the health issues addressed under national Closing The Gap initiatives.
Some of the initiatives MLs are running to contribute to Aboriginal health outcomes include:
• Working with Aboriginal and Torres Strait people and/or organisations to encourage Aboriginal people to self-identify with mainstream services so that they can receive culturally safe care and gain access to Indigenous health services and benefits.
• Educating and training non-Indigenous health providers around cultural safety and informing them of Indigenous entitlements to specific programs and benefits.
• Supporting Indigenous chronic disease management through the Care Coordination and Supplementary Services program.
• Delivering an Otitis Media program for Indigenous communities.
• Employing and supporting Indigenous project officers and outreach workers in Indigenous communities.
Q: There are specific issues related to primary healthcare service delivery between urban, rural and remote areas including the islands of the Torres Strait. What are the highlights, challenges and risks for MLs, especially in remote areas where the divisions of general practice had no footprint?
Claire Austin: MLs are governed locally and they have the remit and flexibility to respond directly to local needs. This means remote residents are shaping their services in accordance with local context. Supporting this is MLs’ mandate to build and maintain local partnerships which are necessary for meeting those needs.
The challenges associated with this are often going to revolve around funding and capacity, so as long as MLs are sufficiently supported by all levels of government and their local communities then they will be well-positioned to overcome these challenges.
Q: How many Aboriginal and Torres Strait Islander staff are employed across Australia by MLs or within AMLA? And how many at manager or higher-level management?
Claire Austin: We know that at least 80 FTE Aboriginal and Torres Strait Islander Outreach Workers (ATSIOWs) and 80 FTE Indigenous Health Project Officers (IPHOs) are employed/funded through MLs.
It is important to note though that MLs do not report to AML Alliance so this type of information is not readily available.
The AML Alliance is privileged to have Uncle Brian Grant as its Special Adviser on Closing the Gap. Uncle Brian is an Elder of the Merriganoury Clan of the Wiradjuri Nation and is a Member of the Council of Elders of the Wiradjuri Nation. Brian provides national leadership advice, assistance and support to the Chief Executive Officer, the AML Alliance Board and operations to assist AML Alliance achieve its aims through the Closing the Gap initiative.
3. Governance and resourcing issues
Q: Who are Medicare Locals’ main ‘customers’? GPs? Primary care service providers in general? Or their local communities?
Claire Austin: MLs have been set up to serve and act in the interests of their communities’ health, first and foremost.
To do this, MLs must work with local providers and stakeholders – who largely influence and impact on the community’s health – to achieve the best outcomes for the population.
As such, MLs recognise the critical role that General Practice plays as the cornerstone of the primary health care system.
To ensure local governance and accountability, MLs are independent companies with boards drawn from the local community. They are skills-based boards made up of a mixture people from different professions, backgrounds and experiences, such as GPs, nurses, allied health professionals, academics, business professionals, community leaders and consumer representatives. They are predominantly held accountable through their members (mixed models exist within the sector), their boards and their funders.
Q: How can MLs demonstrate effective consumer and community engagement?
Claire Austin: MLs are engaging with their local communities at multiple levels and through a variety of means. For example, many MLs have consumer representation on their boards allowing for consumer input into high-level strategic planning and governance. All MLs are engaging the broader community through the development of their population health needs assessments, during health planning activities, service design and development, and service evaluation and review.
MLs are using a variety of engagement methodologies such as holding town meetings; convening focus groups; undertaking surveys; online forums; and talking to identified community representatives and leaders.
AML Alliance is supporting this by providing MLs with resources such as community engagement frameworks and guides, and holding workshops and webinars.
Success of community engagement will be evident in the consumer-centredness of services, such as service access and convenience, continuity of care, appropriateness and cultural safety, and the general satisfaction the community shows with local services.
Q: It is very rare for a national peak body to receive the Government funding at the level provided to the AML Alliance. Most rely on subscriptions from their member organisations. Why do you merit such special treatment? Wouldn’t the AML Alliance speak with greater authority if it was more obviously accountable to those it purports to represent?
Claire Austin: The Commonwealth is cognisant of the value that the AML Alliance provides to MLs as a peak body. It acknowledges that investment in AML Alliance is helping to meet the health needs of Australians by offering leadership, coordination and support of health system reform.
Many peak bodies receive government funding so I am not sure how our case can be construed as ‘special treatment’.
Our funding requirements very clearly state our duty to serve and support the work of MLs, and our governance arrangements have been set up to ensure we perform this task in the absence of undue influence.
The Alliance is committed to supporting and enabling capacity development and excellence for service delivery in primary care through the ML network. It also has a role in identifying opportunities for policy and program improvement at the national scale.
In addition, it should be noted that the Not for Profit Sector Freedom to Advocate Bill 2013 was passed on 5 June, safeguarding the ability of Not-For Profit entities to advocate freely on behalf of the community – which impacts on Commonwealth agreements. The Act invalidates or prohibits clauses that restrict or prevent NFPs from commenting on, advocating support for, or opposing changes to Commonwealth Law, policy or practice.
Q: How well are Medicare Locals and Local Hospital Networks working together? Can you give us any examples of how ML leadership has engaged effectively with the hospital system to build a more seamless service?
Claire Austin: Based on a sector-wide survey, more than 70% of Medicare Locals are currently working with LHNs, including through board cross-representation. This is despite many LHNs still being in their infancy.
For example, the South Adelaide Fleurieu Kangaroo Island (SAFKI) ML is working with its LHN to improve the safety and quality of discharge plans and clinical handovers, share knowledge and data, and reduce waiting times through better internal governance and administrative processes.
Other examples include the Western Sydney and Western NSW MLs which are working with their respective LHNs to deliver the Coordinated Care and Supplementary Services and Connecting Care programs – both of which work to prevent and manage chronic disease in the community and reduce avoidable hospital presentations. These MLs and LHNs have staff secondment arrangements, jointly plan and deliver services and share data, among other things.
Another example is the Health Pathways project that Hunter ML runs in partnership with its LHN. To date it has supported more than 200 clinicians to develop localised, web-based pathways accessible at the point of care. By the end of 2012, there were nearly 40 live pathways and more in development.
Q: Are the ML links to the ‘old’ GP divisions a help or hindrance in setting up innovative services for undeserved or vulnerable populations who would not have had their own GP?
Claire Austin: GP Divisions can be valuable partners to MLs in helping them to engage with and support general practice.
Q: Given that Australia faces a workforce maldistribution problem it is likely that rural and remote Medicare Locals will be actively trying to recruit doctors and other health professionals into their areas. What role do urban Medicare Locals have in mobilising the workforce out of the cities to address the maldistribution problem?
Claire Austin: MLs are actively partnering with rural workforce agencies to address the recruitment and distribution issues facing rural and remote communities. Governments must also assist by continuing to incentivise relocation and support the workforce to stay in rural and remote areas.
I am a member of the Mason review initiated national committee the Rural Classification Technical Working Group, which has been addressing the geographical classifications and application of districts of workforce shortage criteria. These will have a critical impact upon the distribution of the medical workforce.
Q: Do you think the Medicare Local branding has affected perceptions of the roles of MLs?
Claire Austin: The name has initially been confusing for some in the community. The ‘Medicare Locals’ brand is now recognised by stakeholders, who associate it with local primary health care coordination. Re-branding incurs a cost though and governments would need to consider this in light of service delivery priorities.
Q: Are MLs administratively expensive? Please give us some relevant comparisons or indicators.
Claire Austin: The sector-wide ML survey indicated that 73% of ML FTE staff are working at the frontline – in programs (53%), care coordination (16%) and community-based health promotion (4%).
Only 26% have been identified as administrative personnel.
In terms of overheads an example would be the Metro North Brisbane ML’s HACC program in which its overhead costs are 7%.
It should be noted that the AML Alliance is working with our funder to identify and reduce current reporting red tape and create greater flexibility for service delivery.
Q: How can Medicare Locals best influence the development of primary health care when extra funding runs out?
Claire Austin: What extra funds?
Q: Should MLs become full fund holders for some medical services like ambulatory specialist access?
Claire Austin: Fund holding needs to be considered in the context of broader financing reform and objectives.
Q: What should be the next step in bringing more mainstream allied health services into ML?
Claire Austin: A good starting point is building on engagement at governance, community and service provision levels.
Resources for MLs to create and support allied health provider networks, similar to the web-based Mental Health Professionals Network (MHPN), would be a positive step in this direction.
AML Alliance is working with both individual and coalitions of allied health peak bodies – such as the National Primary Health Care Partnership – to inform its support to MLs to better engage with allied health professionals.
Q: Should complementary therapists be encouraged to join MLs?
Claire Austin: MLs determine their own membership models and requirements based on local health needs.
Q: Do you agree that it would be impossible to return to the situation in which such local/regional entities were managed by and for GPs?
Claire Austin: General practice is the cornerstone of primary care and GP engagement at all levels of ML activity – including and especially their governance – is essential if MLs are to be effective in meeting the health needs of their communities.
Q: When will the AML Alliance accept that it is AMLA?!
Claire Austin: Not an issue.
4. What about population health?
Q: Given the lack of direct control over services or their funding, how can Medicare Locals ever achieve the reach that they need to improve the health of the community?
Claire Austin: MLs can largely shape and influence systems and services through partnerships and relationships. For example through joint assessment and planning activities, advocacy, coordination roles and cross-governance arrangements.
There are cases where MLs directly provide services, but where they commission them they have contractual levers to ensure objectives are met.
Greater funding flexibility will help ensure that MLs can apply their resources and leverage to those areas most in need.
Q: How do we stop primary health care getting stuck at the level of extended general practice, and not moving forwards towards more comprehensive primary health care?
Claire Austin: Education, advocacy and support.
We need to change the health care paradigm in Australia and it needs to be led by our health professionals. The current financing system for health does not foster arrangements for working across the social and economic determinants of health.
If we can enable GPs and other primary care clinicians to consider and address the social and economic circumstances that are causing their patients to become ill in the first place, we can start working together on ways to help address those causes. It must be a collaborative effort which includes the development of a more appropriate funding model.
Progress is being made through partnerships for inter-sectoral action. MLs are already partnering with local stakeholders such as local government, business, community organisations and NGOs to identify and help address social determinants of health in their regions. Examples of this were given in response to question seven.
5. Rural and remote health
Q: What is the view of the ‘Local’ in MLs that span one half of WA?
Claire Austin: ‘Local’ refers to MLs’ capacity to identify the needs of, work with and serve the community within their given catchment area. MLs with large geographical boundaries have the expertise, relationships and systems in place to be able to work across these distances in the interests of the community. The added benefit of having fewer larger organisations, rather than a larger number of small organisations, is that they can create economies of scale and improve coordination and efficiency.
Q: As they build up, will funding streams to MLs have weightings to reflect costs and distances in rural and remote areas?
Claire Austin:ML funding already includes rural weightings as determined by the Department of Health and Ageing.
Q: What is the state of play – and the future – re after hours service in rural areas (given that there are few on the ground and they have limited further capacity)?
Claire Austin: Workforce is a major issue for both in-hours and after-hours. If we have the right numbers and types of doctors, nurses and allied health practitioners for in-hours care, then after-hours care will follow. I reject the argument that there are few after-hours services on the ground in rural areas; there are probably few practice-based services but there are still services.
Rural areas have greater complexity and challenges than in metro/regional centres as often the same General Practitioner provides after-hours care for both the hospital emergency department (ED) and the general practice. In addition rural GPs may also be providing aged care, obstetrics anaesthetics, and surgery and other procedural services .
The good news is that with the added flexibility and the additional funding that MLs have access to, they can look at putting in place solutions that work for local communities in rural areas rather than the old after-hours Practice Incentive Program (PIP) ‘one size fits all’ approach which often did not ‘fit’ rural circumstances at all.
Q: Is there a grouping in AML Alliance for the rural and remote ones?
Claire Austin: We work with 61 Medicare locals responding to their individual needs and interests. Where areas of common interest are identified we have facilitated coordinated communities of practice.
Q: Where is the capacity to support genuinely population focused primary health care?
Claire Austin: MLs are already demonstrating capacity to provide population focused primary health care.
This is evident through the development of their population health needs assessments and subsequent plans, the breadth of their partnerships with local stakeholders, their increasing focus on prevention and health promotion and their early activity in addressing the social determinants of health. They will continue to build this capacity as they mature and the AML Alliance is supporting them to do this through capability assessment and performance support.
It will also be reliant on the government providing an adequate level of flexible funding and on reducing any contractual restraints and reporting burdens. AML Alliance is working with the Department of Health and Ageing around this and we are making good progress.
Q: How useful do you and the MLs find the first Health Community reports? http://www.nhpa.gov.au/internet/nhpa/publishing.nsf/Content/Healthy-communities
Claire Austin: The Healthy Communities Reports to date have been useful in providing some baseline data on specific measures, but this is only part of the picture and MLs are drawing on much wider and more in depth levels of data to inform their needs assessments and population health planning.
We understand that the Healthy Communities reports will become more detailed and sophisticated over time and we look forward to working with the National Health Performance Authority in progressing this.
Q: Do you believe that MLs should be local population health fundholders?
Claire Austin: Population health fundholding would need to be considered in the context of broader primary health care financing reform.
Q: Can MLs really impact on preventative health without a budget allocated to do it? (Note how the QLD and SA governments are moving to get rid of their health promotion units, suggesting that the MLs are taking up this responsibility)
Claire Austin: MLs are already having an impact in preventative health. They are doing this by working with local partners to run:
• health promotion campaigns around smoking, diet, exercise and alcohol
• health literacy initiatives including education and support with self-management
• healthy lifestyle coaching and assistance, such as exercise and healthy eating classes
• education and support initiatives for health professionals to provide preventative and early intervention care, such as through the development and dissemination of evidence-based chronic disease best-practice guidelines and resources
• initiatives that identify and address social determinants of health, such as around transport, town planning and community development
It is unnecessary to allocate a specific budget to preventative health. Governments should instead be increasing flexible funding to MLs to allow them to determine and subsequently address what the preventative health care needs are of their local communities.
MLs can do this more effectively if they are not constrained by prescribed and siloed funding arrangements.
It is important though that funding increases – including through investment from the states.
Without this MLs will be limited in the impact they can have in reducing the hospital burden.
Q: Given the evidence supporting the importance of the social determinants of health in addressing health inequity, how should MLs encompass a SDOH approach to improving health in their communities?
Claire Austin: MLs are already helping to address the social determinants of health (SDH). In addition to the examples provided in a previous question – regarding Barwon ML’s G21 Regional Alliance participation, and Northern Territory ML’s community gardens project,
Gold Coast ML has partnered with a range of organisations with SDH expertise and influence to co-develop its three year Health and Wellbeing Plan. These include Queensland Health’s Gold Coast Public Health Unit, Queensland Department of Communities, Child Safety and Disability Services, Gold Coast City Council (Social Planning and Development, and Corporate Planning), and with support from the Australian Department of Families, Housing, Community Services and Indigenous Affairs, and Griffith University’s Urban Research Program. Gold Coast has also made “Integrate Social Determinants into Health Care Planning” one of its key strategic plan objectives.
Similarly, Tasmania ML has prioritised SDH in its work plan, implementing a specific “Social Determinants of Health Project” starting from January 2014, which will be overseen by a Social Determinants of Health Manager and Coordinator. Its guiding principles for the project include working collaboratively with key stakeholders, and developing trusting and respectful partnerships across multiple sectors.
MLs will continue to build their capacity and expertise in the SDH space by partnering with multi-sectoral stakeholders to influence and shape local social and economic conditions and programs. The AML Alliance is supporting them to build these partnerships and to incorporate SDH thinking and activities into their work plans through dedicated workshops, resources and support, largely driven by AML Alliance’s Principal Policy Adviser, Population Health, who has extensive SDH expertise.
Q: What is the evidence that MLs are having any effect on practice systems or behaviour to enhance chronic disease management?
Claire Austin: Evidence is available through a review of the Pen Clinical Audit Tool and Australian Primary Care Collaboratives data.
Q: At the AML Alliance conference last November, you and Bob Wells (Director, APHCRI) signed an MOU, which has quite a focus on research. Has anything changed as a result of this MOU, what has been the value of this exercise? http://www.amlalliance.com.au/__data/assets/pdf_file/0011/46748/20121110_med_nc_aphcriMOU.pdf and http://aphcri.anu.edu.au/sites/aphcri.jagws03.anu.edu.au/files/news/418/20121105_mou_apchri_mou_final.pdf
Claire Austin: APHCRI and the AML Alliance recently co-developed a monograph exploring the effectiveness and cost-effectiveness of primary health care and primary health care organisations, examining comparable overseas examples.
APHCRI, AML Alliance and HealthDirect Australia are jointly exploring how their population health planning tools can complement each other to most effectively and efficiently assist MLs.
AML Alliance and APHCRI have partnered to help create the new NHMRC Partnership Centre for Better Health: Primary Care – System, Services and Workforce Innovation.
With plans to strengthen its primary health care research agenda and capacity, the AML Alliance anticipates building on its relationship with APHCRI.
6. What about mental health?
Q: What contribution are MLs making to enhanced mental health care on the ground? And particularly the significant physical health needs of those with more severe mental disorders?
Claire Austin:MLs manage and coordinate the Access to Allied Psychological Services (ATAPS) program which provides people with mild to moderate mental health disorders access to effective low-cost treatment from an allied mental health professional. To date, there has been more than one million sessions provided through ATAPS, with a recent evaluation finding that consumers of these services are improving their outcomes in more than 86% of cases.
Many MLs are lead partners in the headspace National Youth Mental Health initiative, helping to deliver and coordinate mental health services to thousands of young Australians.
85% of MLs are the leads in the new Partners in Recovery initiative which takes a holistic, integrated approach to helping people with severe and persistent mental illness.
The AML Alliance recently participated in the National Summit: Mental Health and Physical Health hosted by NSW Minister for Mental Health and Healthy Lifestyles and the Australian Minister for Mental Health and Ageing, to develop a way forward on addressing the premature death of people with severe mental illness. AML Alliance will continue to work with this initiative to identify where MLs can play a role in addressing this important problem.
South Australian MLs are already rolling out initiatives that specifically address mental and physical co-morbidities.
Q: To what extent are they adding value to new mental health programs as distinct from simply administering new funds?
Claire Austin: MLs are partnering with local service providers and undertaking population health needs assessments to identify mental health service gaps and duplications. They are then working with providers fill those gaps and coordinate services to minimise inefficiencies. Helping to make the best use of resources, it allows for any potential savings to be reinvested back into local services so that consumers can get the right care in a timely manner, with increased convenience.
Q: What are the key questions should journalists be asking about federal election health policies?
Claire Austin: If the party is committed to organised primary health care, what sort of funding should be directed towards Medicare Locals?
Does the party believe in devolving funding and responsibility at the grassroots level to achieve locally determined health services?
What’s the party’s 10-20 year vision for Australia’s primary health care system?