Helpful advice for Minister Dutton: on the review of Medicare Locals, and other priorities…

Given that Health Minister Peter Dutton is so busy slashing federal health agencies (anyone who finds this surprising clearly hasn’t been paying attention), Croakey contributors have helpfully come to the new minister’s assistance, offered lashings of advice on some of his other pressing tasks.

The Minister should be able to save a small fortune on consultancy fees, thanks to the advice below on:

• Priorities for the first 100 days of government
• Terms of reference for the review of Medicare Locals promised before the election
• Suggestions for who could contribute to this review
• Suggestions for new names for the organisations.

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1. Your top two priorities for the new Federal Health Minister in the first 100 days of government?

Professor Helen Keleher, Monash University
Commit to continue the reforms in primary health care in recognition of the need to reduce the burden of illness on Australian society.
Implement COAG decisions on mental health reform in recognition of the impact that mental health issues have on Australian society.

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Professor Mark Harris, UNSW
Resolve the status of the various organisational structures including Medicare Locals, ANPHA, NHPA etc.

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Professor John Dwyer, UNSW
1. Restore the cost of living adjustment for GP remuneration. Only 13 % of medical students are interested in exploring careers as GPs and no wonder when they hear of how little is being done to help these vital specialists who are treated by government as anything but!
2. Ask the States for a review of the current success or otherwise of activity based funding, hospitals across the nation are struggling to meet budget. We need the new government to have primary health organisations set up demonstration models of truly Integrated Primary Care.

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Alison Verhoeven, Australian Healthcare and Hospitals Association
The AHHA is seeking an early indication from Minister Dutton regarding his views on the national health reform agenda, the key principles which underpin it, and rationalisation of activity and investment to ensure it achieves the original goals and objectives of a high quality, safe, effective and efficient healthcare system for Australia. In particular, we would like clarification around the proposed diversion of funding to frontline services, and the scale of any likely funding cuts.

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Carol Bennett, Consumers Health Forum
1. Establish a review into Medicare, assessing issues such as output/performance-based payments, rethink the mode of payment for chronic care and solutions to rising out of pocket costs.
2. Review PBS arrangements including listing, price and the future of community pharmacy agreements and ways to maximize stakeholder input with the aim of achieving better health outcomes.

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Daniel Reeders, public health professional
1. Commit to Aboriginal communities having more say over how Closing the Gap spending and programs are planned and delivered in their local areas.  The principle is ‘nothing about us without us’, which is an activist war cry but also a pithy re-statement of the conservative political value of belief in the strength of local communities. Talk of creating an appointed, top-down advisory council was about creating the appearance of decisive action for the nationwide media during an election campaign — now the campaign is over, it should be quietly dropped.
2.  Take decisive action to fix the National Bowel Cancer Screening Program. Screening via FOBT is recommended every two years from age 50.  The national program sends a kit in the post every FIVE years.  Bowel cancer is more easily treatable if caught early.

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Professor Pat McGorry, psychiatrist
1. Mental health reform, especially finishing the youth mental health system build and repurposing other funds to support housing and employment for the seriously mentally ill.  Also forcing States to hand over or ring fencing community mental health budgets within public hospitals. Finally removing mental health care from emergency departments.
2. Drug and alcohol service investment.

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A medical leader who wished to remain anonymous
1. Strengthen primary care
2. Improvements in Indigenous health

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Lewis Kaplan, General Practice NSW
Don’t just talk to doctors or their representative organisations.  And don’t get trapped into building more hospitals.  It’s like building more gaols to address criminality – we need to focus on the causes of poor health not just the results. Investing in general practice is not necessarily investing in integration or coordination of care for chronic disease.

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Sally Crossing, Cancer Voices Australia

1. Remove the ability to patent human genetic material. Australians need a commitment by the new Health Minister to draft legislation to remove the ability to patent human genetic material. We could wait years for the courts to work though the molecular biology arguments in which they find themselves. This is not really a legal matter, but an ethical one – at most an unintended consequence of legal interpretation.  We need to provide certainly for patients, researchers and ethicists. The Australian community finds it disturbing that bits of our bodies can be owned by commercial interests, researchers find it frustrating and patients find the current status limiting and uncertain.
2. Speed up drug approvals processes. While maintaining the integrity of the TGA, PBAC and MSAC approvals processes for new drugs and co-dependent technologies, commit to streamlining and reducing the time between registration and decision, so that Australian patients are not waiting longer than those in other western countries for access to proven innovative therapies.  Also arrange to prune the approved lists for subsidy of superseded drugs.
3. Prioritise and streamline clinical trial reforms. As we move further towards personalised medicine, the number, purpose and design of clinical trials need to change.  We would like to see the new Government take up a nationally coordinated approach to clinical trials, including a review of the effective role and numbers of ethics committees.

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Dr Peter Parry, child & adolescent psychiatrist
Push for transparency on relationships between pharma/device makers and medicine/surgery.

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Professor Jill White, University of Sydney
1. Understand the important gains made in relation to maternity services and continue them; go back to the health and hospitals reform commission report and implement the primary health care strategy.
2. Build integrated community health centers with excellent public transport links to them.

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Lea McInerney, writer and facilitator
Health economics analysis of end of life treatment and over-treatment and potential for reinvesting those funds in primary health care and social determinants of health-related policy reform.
Note this work coming of US from Katy Butler ­– be good to do similar investigation in Australia (with or without the personal stories).
Book review: http://www.nytimes.com/2013/09/08/books/review/knocking-on-heavens-door-by-katy-butler.html?pagewanted=all&_r=0
Excerpt: http://online.wsj.com/article/SB10001424127887324577304579054880302791624.html?mod=wsj_share_tweet
Another excerpt published in Tricycle http://www.tricycle.com/feature/life-too-long

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2. Your top three suggestions for the terms of reference for the review of Medicare Locals?

Professor Helen Keleher
1. Determine the most effective strategies to improve access and equity to primary health care services
2. Determine the need for Australia to build and retain international best practice in primary health care to reduce the burden on hospitals and to keep people productive, well, and out of hospital
3. Ensure that primary health care organisations are resourced sufficiently to improve health outcomes for all Australians and to ensure the sustainability of the primary health system and require infrastructure.

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Professor Mark Harris
There is really no point in a review if the intention is not to continue.  If the intention is to improve them then the terms of reference should include:
1. What have their achievements and challenges been in terms of the 4 priorities areas outlined in the primary health care strategy and the COAG strategic framework for primary health care (access and equity; chronic disease; prevention; quality, safety and performance).
2. How effectively do they integrate care with state , private and NGO health services
3. What are the priorities for their future focus in planning and delivering local health services.

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Professor John Dwyer
1. More clearly define the role expected for MCLs
2. Define assessment criteria for their performance
3. Debate the wisdom of redefining their geographic boundaries to align them with LHDs and have them structurally and governance wise tied to LHD Boards

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Daniel Reeders
1.  Reducing the burden of accountability evaluation and increasing the priority of taking action to ‘see what works’, which includes learning what to evaluate and how from early experiences and community engagement.
2.  Reducing the focus on upfront planning and increase the emphasis on brokerage and coordination.  Rudd made a fetish out of ‘detailed programmatic specificity’ and it really shows in the plans to make plans for more plans — always a temptation for a new government.  Some of the most exciting work in the primary health space in Victoria involves bringing parties together and creating partnerships rather than top-down setting of targets and identification of strategies based on evidence and de-contextualised from real world relationships.
3.  Take the ‘local’ part more seriously.  What kinds of health issues could better be dealt with at a national or state level?  What health issues really depend on local determinants?  Make sure MLs are dealing with the latter.

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A medical leader who wished to remain anonymous
1. Are they delivering what was promised in terms of increasing frontline primary care services for the community?
2. Do they deliver value for money?
3. What is the evidence that they are truly engaged with local general practices and other primary care services?

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Lewis Kaplan
Please consider using the information coming out of the evaluation which is already underway (Ernst & Young + CPHCE (UNSW)) and completely independent.

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Alison Verhoeven, AHHA
The review should consider the extent to which  MLs have achieved better integration of care, including improved levels of primary care to ease the pressure on hospitals. It also needs to consider the extent to which autonomy of governance arrangements at community level have been achieved, and whether the current performance reporting and other national administrative infrastructure is the most appropriate model.

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Sally Crossing, consumer health advocate
Just make sure they are actually serving their communities in ways that are needed!

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Professor Jill White, Dean, Sydney Nursing School, University of Sydney
Look explicitly at the educational opportunities for health professional placements with these organisations and the capacity for working to full scope of practice for all

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Carol Bennett, Consumers Health Forum
1. Given the varying levels of active achievements so far among Medicare Locals, what are the characteristics of those that are achieving and those that are not, in terms of consumer and community input and responsiveness?
2.  To what extent are MLs improving coordination of care and access to allied care?
3.  What evidence is available so far to show the extent to which MLs are reducing demand for hospital care?

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3. Your suggestions for who should oversee this review and for members of the review committee?

Prof Helen Keleher, Monash University
Prof Steve Leeder to chair
Members of the review committee: Michael Moore, Professor Helen Keleher, Dr Mark Harris

Prof Mark Harris, UNSW
Should have an evaluation committee which should include representation from professional groups (GP, allied health), states, consumers, academics/research, Medicare locals, NGOs (eg heart foundation)

John Dwyer, UNSW
Review should be done by a committee which would include representatives of Health Consumer groups, Clinical academics ( their teaching role( MCL) into the future will increase in importance) The college of GPs  University academics studying PC, Allied Health, Nursing, National prevention committee.

Daniel Reeders
At a bare minimum I’d want to see Fran Baum on it — the South Australian approach to ‘health in all policies’ (HiAP) and her work on critical public health (using humanities and the social sciences, not just health sciences) has a lot to offer.

Jill White, University of Sydney
Senior nurse and senior midwife as a start

A medical leader who wished to remain anonymous
I am not sure if any of the following will welcome being suggested, but the following are all respected and are likely to be listened to by the coalition:
Bill Glasson
Kate Carnell
Rob Walters.

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Lewis Kaplan
If he does have to establish a new review process, ask Prof Kathy Eagar from Wollongong University to chair.  (I’m also available.)

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Alison Verhoeven, AHHA
It will be important for public hospitals and healthcare providers to be represented on the review committee, along with consumer, primary health and allied health care representatives.

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Carol Bennett, CHF
Claire Jackson, Michael Wooldridge, Stephen Leeder,  Karen Carey.

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4. It seems a fairly safe bet that the new Government will change the name of “Medicare Locals” (if the organisations survive). What name would you prefer?

Prof Helen Keleher
Primary Health Care Organisations

Prof Mark Harris
Primary Care Local (removes confusion with Medicare, provides some continuity of idea)

Prof John Dwyer
Primary Health Care Organisations (PHOs). We should have the above committee explore the NZ system wherein PHOs offer services including secondary care (23 hour wards etc.) and supply services to clinically autonomous small practices in their region.

Prof Pat McGorry
Medicare Locals should become “Community Healthcare Networks/Platforms”

A medical leader who wished to remain anonymous
a. Healthcare Hubs is my favourite.
b. Primary Care Associations, Primary Health Care Organisations, Primary Care Collaboratives, Primary Care Trusts, have all been suggested but the public (and many in the professions) do not really understand the term “primary care” and these could be just as confusing as Medicare Locals.
c. Divisions of General Practice is not bad.
d. Integrated Total Community Health, because I like the acronym.

Daniel Reeders
Primary Health Brokers

Lewis Kaplan
Or the vision of Medicare as a universal system could be extended beyond a basic re-imbursement system to Medicare Prevention, Medicare Disability, Medicare Mental Health etc. etc…    the name ‘Primary Health Care’ is clearly already taken, otherwise it would have been ideal.  If a name change has to happen, how about Primary Care (region) or Coordinated Health (region).

Sally Crossing
The name does indeed need to be changed and should reflect what they are supposed to be doing with a lot of public money.

Professor Jill White 
Integrated community health.