Health Minister Peter Dutton has flagged the possibility of big cuts and changes for Medicare Locals in the coming Federal Budget, saying he wants to make sure health funds are being spent “on frontline services, not on bureaucracies”.
In the post below, two Medicare Local CEOs argue that the ‘local’ in their names is key to their importance, and to future cost savings.
Local control (and rebuilding primary care) is also an important part of the Coalition’s pre-election commitment on health .
In the first article, Kristin Michaels, CEO at Eastern Melbourne Medicare Local, says that localism has become a fashionable term, but really means “health consumerism” – how we employ, expend and exploit our resources.
She writes:
And right now, we’re worried that people are consuming the wrong thing, and too much of it; too much of our hospitals, and not enough of our knowledge about how to stay healthy or manage illness or disease at home. It’s costing us an enormous amount as a nation, and we all agree it’s unsustainable. So how do we get health and healthcare consumed in a manner that improves individual health outcomes, individual lives? How do we make sure that people are consuming better health like it’s an end of season sale?
Leanne Wells, CEO of ACT Medicare Local in Canberra, says the debate should not be over whether Medicare Locals are “another costly layer of bureaucracy” but rather should be asking: at what level in the system is health leadership and management most effective? Is it best done centrally or on a more decentralised, local basis? She writes:
Medicare Locals are an alternative form of health system management. Planning and decision making by people ‘close to the action’, who know what is happening in local health systems and who work together across primary care, aged care, social care and hospital services equates to better system design and more responsive services better targeted to the needs and profiles of communities.
For more about the work of Medicare Locals, keep an eye out this week on Twitter for @wepublichealth – this week featuring Jason Trethowan, CEO of Barwon Medicare Local in Geelong, Victoria, and Deputy Chair of the G21 Region Alliance Board.
Finally, Pain Australia has also urged the Federal Government not to dismantle Medicare Locals, saying chronic pain is best managed in the community, not in a hospital setting, and that Medicare Locals are providing the “ideal framework” for this. See its media release.
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Is Localism healthy?
Kristin Michaels writes:
Localism has recently become a bit of a fashionable term, particularly popular in local government circles. It’s been increasingly cast about in health as potentially offering a solution to long-term inequities and variability in health outcomes across communities. That said, it seems that many are still unsure what localism really means, and whether it is an effective conceptual model to guide health service development and models of care across our vast nation.
I recently read that the internet had conquered the tyranny of distance in Australia. A big statement indeed. Many health services are certainly utilising technology to breach the gaps between city and country. Telemedicine, eHealth and remote patient monitoring are increasingly being trialled effectively, particularly in the acute and private sectors, and people report liking the services…not usually more than seeing their doctor face to face, but far more than travelling for hours, or not getting access to a service at all.
So in light of our increasingly impressive technology and virtual neighbourhoods, does localism really deserve much attention now or into the future?
I think that it does. In fact, more than that, I think it addresses many of the really difficult issues in healthcare today, and it does it through a primarily preventive lens.
Demographically, people stick together. Essentially most of us want to live, play, eat and do stuff with people who like similar stuff to what we do. And most importantly, we like our favourite cafés, shops, parks, and services to be nearby. For the most part this is so we can get to it quickly, and make it all fit into our increasingly busy and difficult lives. And naturally we make choices about what we do and buy based on what’s easily available to us in our local neighborhoods.
Where I live (in inner Melbourne) there are six different gyms within a five block radius of my apartment. There are grocers (organic obviously because that’s what people in inner Melbourne like), two yoghurt shops, four sushi bars, three pharmacies, two general practices, a sports medicine clinic and a vet, all within walking distance of my front door. I could even walk to my nearest Emergency Department if I had the need. In fact I’m lucky enough to live in a suburb that has a walkability rating in the 90s, which makes it one of the healthiest places to live in Australia.
In contrast, where I used to live (in outer urban Melbourne) I had to get in my car just to get to the supermarket, there was only one doctor within close driving distance and sometimes you couldn’t get in to see him because he was too busy, and there was definitely no sushi! So people walked a fair bit less, they ate a fair bit less fresh food and got a fair bit more take-away on the long drive home from work because there wasn’t much else open after 6pm. Now, I’ve never lived in a rural area (unless you count Canberra), but I’ve worked in them, and goods and services are simply harder to come by. Sometimes impossible. Some of those things are essential to keep the community healthy, like doctors, nurses, fresh fruit and vegetables.
So where you live, who else lives there, and what’s happening around your local area is pretty important. And it can have a big effect on your health.
It’s no coincidence that the National Health Performance Authority’s Healthy Communities Report on Overweight and Obesity Rates Across Australia released late last year reported that the five local areas with the highest percentagesof overweight or obese adults were regional and rural catchments in five states: Western New South Wales with 79 per cent of its adult population, Townsville-Mackay in Queensland (75 per cent),,Country South South Australia (75 per cent), Gippsland in Victoria (75 per cent), and the Goldfields-Midwest in Western Australia (74 per cent). Does anyone find it surprising that mega-brand The Biggest Loser recently showcased Ararat, in rural Victoria, as Australia’s fattest town?
As an aside, each of the Medicare Locals is due to submit a Comprehensive Needs Assessment (of population health needs in each catchment) the day after the Federal Budget, ironically, that will look in depth at the needs of their catchment populations, and sub-populations within them.
These CNAs offer one of the first truly detailed and locally specific assessment and planning mechanisms for our communities’ health prepared in consultation with both communities of practice and communities of residence. They offer an insight into the demands made by our local populations because they view those populations at a ‘local’ level, and they offer a platform for shared decision making with communities about how health services could and should respond in a localised fashion.
At Eastern Melbourne Medicare Local for example, we provide a large and comprehensive mental health service for our communities. But those services look very different in rural Healesville where the local Aboriginal community have worked with us to design an arts therapy program for young people, to how they look in urban Knox where we have worked with GPs, headspace and the Local Hospital Network to establish a community-based eating disorders clinic. Both services meet a specific need for young people living in very different settings. They’re local services.
This work will be a major support to health system management and re-design that Leanne Wells is talking about (in the post below). Surely that’s an investment worth building on!
But our health challenges aren’t solely driven by geography, and they’re not solely about a metro/rural divide either. They stem from complex social, cultural, financial and sometimes even familial factors. In health we talk a lot about care being managed in the community, for reasons of cost savings and ‘appropriate’ settings. We don’t talk much about the fact that people just want to get their healthcare like they want to get everything else: easily, in a setting that makes them comfortable, from people who are also part of their local community and understand what makes it tick. And that goes for everything from advice about how to live a healthier lifestyle to hard-core medical interventions. So localism is really just a fancy word for health consumerism. And consumerism is all about consumption; how we employ, expend and exploit our resources.
And right now, we’re worried that people are consuming the wrong thing, and too much of it; too much of our hospitals, and not enough of our knowledge about how to stay healthy or manage illness or disease at home. It’s costing us an enormous amount as a nation, and we all agree it’s unsustainable. So how do we get health and healthcare consumed in a manner that improves individual health outcomes, individual lives?
Simple. We cease assuming that the same model of care and service will work everywhere in Australia. We localise health. There’s a reason that our local family doctor is our first port of call when we feel unwell. GPs generally live where they work. They’re part of the local community, like the people they treat. Their practice fits with the lives people have chosen to live in their particular places. They are local, and they provide what their local community needs. Life will always be different in Ararat to what it is in inner Melbourne. Because of this our community’s health needs may also be different, but our health outcomes needn’t be.
Decisions can’t be made for outer urban and rural Victoria based on what works in inner Melbourne. Local people know what they want and need, and how they want it delivered. We just need to ask them. And we need to be free to respond flexibly because localism is essentially good consumerism. And we want people to be consuming better health like it’s an end of season sale.
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Why we can’t ignore the evidence for Medicare Locals
Leanne Wells writes:
Recent weeks have seen a focus on the future of Medicare Locals in the lead-up to May’s Federal Budget. Among the speculation there is one resounding message from health commentators: the case for a local, clinically-led, community-connected structure for better organising and supporting primary health care is strong if we want an affordable, responsive health system.
What difference do organisations like ACT’s Medicare Local make? Why would that value be so hard to rebuild should it be eroded?
The way clinicians, service providers and consumers behave and interact is key to our health system working more effectively and efficiently. At ACTML we are committed to putting Canberra’s clinicians in the driving seat to work in partnership with ACT Health, consumers and the community to co-design the way the local health system should work.
Already, we’ve worked alongside local clinicians to introduce new mental health, after hours and aged care solutions among many other programs.
But any number of agencies can efficiently deliver services. Medicare Locals have local, fit-for-purpose governance arrangements and a full spectrum of tasks that include planning, coordination and integration of care, support for clinicians and service delivery. It is these functions, in combination, that make them unique.
At ACTML our work builds on the longstanding work of the ACT Division of General Practice linking GPs into the health system.
A certain level of management and administration is required to translate policy into programs and services. Rather than debate whether Medicare Locals are another costly layer of bureaucracy that should be rationalised, we should ask: at what level in the system is health leadership and management most effective? Is it best done centrally or on a more decentralised, local basis?
Medicare Locals are an alternative form of health system management. Planning and decision making by people ‘close to the action’, who know what is happening in local health systems and who work together across primary care, aged care, social care and hospital services equates to better system design and more responsive services better targeted to the needs and profiles of communities.
The health system is complex and difficult for both clinicians and patients to navigate. The unique value proposition of ACTML and our fellow Medicare Locals is our capacity to serve as system stewards and to harness local knowledge, link the system, connect providers, design clinician and community-led solutions and deliver and coordinate frontline services.
Speaking last year at ACTML’s annual Symposium, international health systems researcher Dr Judith Smith said that global lessons take us back to the pressing need to change how we provide health and social care services. We have ingrained models of health provision and persistent fragmentation of care. All too often the links that should be there to smooth the patient journey between hospital and their GP and between health, social and aged care services break down. We have ongoing pressure on emergency departments and avoidable hospital admissions that, if prevented and managed through the primary care system, would save the taxpayer considerable amounts. Judith says the future is about the hard work of changing care provision. It’s about doing the hard thinking to shift the balance of care away from institutions and into the community. Is it possible? This is the focus intended for Medicare Locals.
Medicare Locals have rapidly earned the backing of clinicians and the community to become the game changers in health reform. They are poised to provide support and development for primary care as it seeks to operate at greater scale, to enable networks of providers, support new approaches to funding and contracting for coordinated care and to better integrate specialist and social care services with primary health care.
We should embrace Medicare Locals’ centrality to the health system and their capacity to keep people well and out of hospital. To disrupt Medicare Locals’ progress now would be retrograde and a setback for a better health system.
Leanne was formerly CEO of the Australian General Practice Network and Transitional CEO of the Australian Medicare Local Alliance.
