Health reform: in whose interests? And what happened to the vision for primary healthcare reform?

It is always worth reading when The Australian’s Mike Steketee turns his mind towards health matters.

In this latest column, he gives a useful overview of ongoing challenges for health reform, noting that “governments come and go, but in health it is the vested interests that continue to run the system”.

A similar conclusion could be drawn from another incisive piece of analysis, re-published below from The Health Advocate, the official magazine of the Australian Healthcare and Hospitals Association.

Lyn Morgain, CEO of the Western Region Health Centre in Victoria, argues that Medicare Locals are a disappointingly long way from the original vision of primary health care reform.

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Medicare Locals and disadvantaged communities

Lyn Morgain writes:

Over the past year there has been extensive discussion of reform to the Australian healthcare system generally and the primary care system in particular.

On the face of it, such a discussion would have to be good news for the advocates and providers of community health.

Unfortunately, the reality is a little more complex and ultimately disappointing.

Many proponents of the community health model are less than overjoyed by the way the proposed changes have taken shape. This is not because elements of the announced reforms are not good. Many, in fact most, are.

The disappointment lies in the fact that initiatives that were originally mooted by the National Health and Hospital Reform Commission contained such genuine promise, reflecting an explicit commitment to many of the theoretical models and values central to the mission of community health.

The reforms articulated an explicit commitment to addressing health inequity, the premise upon which the community health sector is built, and a policy level recognition that in order to promote greater equity:

“… universal entitlement needs to be overlaid with targeting of health services to ensure that disadvantaged groups have the best opportunity for improved health outcomes”.

The recommendations entailed a clear recognition of the importance of community and consumer involvement in decision-making and a commitment to:

“The development of accessible information on the health of local communities. This information should take a broad view of the factors contributing to healthy communities, including the ‘wellness footprint’ of communities and issues such as urban planning, public transport, community connectedness and a sustainable environment”.

This was powerful and reforming rhetoric indeed. If realised, it might have matched Prime Minister Gillard’s recent claim to have delivered changes to the ‘centre of gravity’ of the health system – any trace of which is entirely absent from the mechanics of the present initiatives.

These social equity and participatory principles have been replaced by a deceptively similar but in fact, altogether different focus on care coordination and providing a means of addressing gaps in clinical care by groups of local clinicians. Led by GP driven organisations competing with the acute sector for funds. This is a long way from the original vision.

There is a feeling of considerable disappointment and frustration among advocates of a social model of health, a model that holds that community control over the environmental influences of health is central to the shift required in the health system if real change is to occur.

The Medicare Locals (MLs) that form the centrepiece of the primary care aspect of the reforms embody much of what has gone awry with the original aspiration of the reform agenda.

They have come to represent the now entrenched conflation of primary care and the altogether different business of prevention, health promotion and community control over determinants of health. While these entities may deliver on the former they stand little chance in their present form of realising the latter.

Despite the rhetoric, MLs as presently constituted, have very little to do with health inequity and even less to do with community control. Genuine local community involvement in these new entities is almost entirely absent, even less the role of communities of identity or those most marginalised.

Unless, of course, clinicians groups and Board Directors are to be read as proxies for broad based, diverse community interests. Or the promised reports to communities on funding and clinical pathways are considered sufficient.

For the uninitiated, MLs as they stand today are to be Pty Ltd, governed by skills based boards at arm’s length from government, based in most cases on pre-existing Divisions of General Practice.

Their key functions are to:

• make it easier for patients to access the services they need, by better linking local GPs, nursing and other health practitioners, hospitals and aged care services, and maintaining up-to-date local service directories;

• work closely with Local Hospital Networks to make sure that primary healthcare services and hospitals work well together for their patients;

• plan and support local after hours face-to face GP services;

• identify gaps in service provision in local communities and coordinate services to address those gaps; and

• support local primary healthcare providers, such as GPs, practice nurses and allied health providers to adopt and meet quality standards.

Terrific (primary care) objectives but entirely devoid of any reference to health inequity or consumer control, a practical problem for the identification of gaps and coordination of services to address those gaps. Particularly if those gaps happen to be related to health equity issues which impact those most marginalised.

The experience of the community health sector suggests that to target the long term and intractable health issues affecting particular communities, for example refugees, homeless, or those with low literacy or mental health issues, one needs to adopt long term development initiatives, aimed at relationships with communities. Partnerships in which communities design, develop and deliver solutions.

Many of these solutions are neither clinical nor medical but related to infrastructure, home, places to play with children, work and related dignity, education and the capacity to understand and influence choices.

They also usually involve the opportunity to express hopes and aspirations, identify failings in the treatment system, complain and advocate for changes to policy.

This is the business of community health and the activity that stands to be lost in a policy environment in which the only needs are clinical and the only requirement to coordinate services.

Health as we know it, is about so much more than that.

In the rush to establish MLs, Divisions of General Practice and politicians both have attempted to demonstrate community partnerships. These partnerships have been largely focused on demonstrating a capacity to coordinate care and develop integrated models across sectors. Perhaps inevitably these discussions have tended to treat the role of GPs as central to primary care provision.

What they have not demonstrated is capacity to undertake authentic population health planning, a genuine commitment to consumer involvement or any awareness, skill or experience in working with local networks, coalitions, alliances or within integrated models that bring together health, education, social welfare and housing sectors.

Community health models in contrast have consistently demonstrated over time the opportunities available to communities when clinical care is contextualised within a full range of social and community supports that can greatly enhance the repeatedly promised ‘right care, and the right time, by the right professional’.

Those of us committed to this process will need to work hard to ensure these understandings truly inform our new system.

• This article first appeared in The Health Advocate: Issue 11 October 2011.

(Update: references available on request to Croakey)