This week has brought plenty of interesting reading on Medicare Locals, with new publications that are worth reading from the Australian Health Care Reform Alliance, Consumers Health Forum, and a joint effort from the Australian Medicare Local Alliance and Australian National Preventive Health Agency.
Details and links to these documents can be found at the bottom of the post.
In the article below, two leaders of the North Coast (NSW) Medicare Local (NCML) describe their recent journey with the new organisation, which set up shop in April. Vahid Saberi, the CEO, and Tony Lembke, a GP in Alstonville and the Chair, have been involved in a series of roundtables and public meetings over the last week in different parts of their region.
The NCML was auspiced by the four divisions of general practice from the region, and by the Many Rivers Alliance of Aboriginal Medical Services and by North Coast General Practice Training. It serves the region from Port Macquarie to Tweed Heads, with a population of over half a million. The region has among the highest rates of population growth in Australia and among the highest rates of people over 65. And 3.5% of the population identify as Aboriginal (NSW as a whole 1.9%)
While it is very easy to find critics of the name, “Medicare Local”, Tony Lembke wrote to Croakey saying that he had grown to appreciate it.
He wrote: “With regard to the Medicare Local name, the ‘local’ part is a good idea – ‘local’ resonates with a regional community. It is not Sydney or Canberra. The fact that we are locally owned (by the local community and local clinicians) is an important part of gaining the necessary goodwill and sense of ‘belonging’ we need to be effective. I’m unconvinced by the ‘Medicare’ part of Medicare Local – however, you get used to it after saying it a few thousand times.”
What do Medicare Locals do?
Vahid Saberi and Tony Lembke write:
The recent comments by Peter Dutton and Tony Abbott about Medicare Locals have received some media attention. The Opposition leader, Mr Abbott, stated that he is unsure what Medicare Locals will do.
Mr Abbott’s statement is sincere and does not surprise us. This is probably how many clinicians and community members feel.
It should not surprise anyone that in the midst of major change and reform a degree of uncertainty exists. This is especially true in the crowded, dynamic and diverse health care environment.
Mr Abbott also stated that he understands what the former Divisions of General Practice did, and he supports the Divisions. In fact in April 2004 the then Federal Minister for Health and Ageing Mr Abbott, in response to an independent review of the role of Divisions of General Practice stated: “The Government believes that the development of the Divisions network has been one of the most important health innovations of the last decade”.
We would hazard a guess that 3-6 months after the formation of the Divisions of General Practice, Mr Abbott, like many others, would not have had much clarity about what the Divisions did.
The Divisions of General Practice were established in the 1992/93 Federal budget. The objective being to provide infrastructure and project funding to enable GPs to develop local networks, improve integration of the health system and help meet local needs.
In 1997, the Australian Medical Association (AMA) expressed concern about the establishment of the Australian Divisions of General Practice (ADGP). However in 2002, AMA had seen the benefit of ADGP and in the conclusion of its submission on the Review of Role of Divisions of General Practice stated: “The AMA strongly supports the concept of Divisions coordinating GP activities at a local level…”. AMA went on in its submission to make some constructive recommendations for improvement.
The point is, it took years for the Divisions of General Practice to evolve and define their roles within the national health environment. Divisions were subsequently acknowledged as a valued part of the Australian health care system – even being highlighted by some as a significant and the only major structural reform in the provision of health care services since Medicare began in 1984. (Scott and Coote, 2007)
Medicare Locals will largely continue from where the Divisions have left off and extend the work to all primary health professionals. Primary health care by definition is the front line care provided outside the hospital setting by multidisciplinary teams, at the centre of which is General Practice. It is only appropriate that the support given to GPs by the former Divisions is extended to all primary health care providers. This will be done by Medicare Locals. Every year on average Australians have 22 encounters with the health system. Over 90% of these are in the primary health care domain. The challenge is that this space is fragmented, and the care is not delivered in a patient centred and cohesive manner.
A strong primary health care system is crucial to well developed, efficient and equitable health care. Many countries have established regional primary care organisations akin to Medicare Locals.
Medicare Locals provide the opportunity for change, in a way that we have not seen in Australia. For at least two decades, or more, we have been talking about the importance of primary health care.
This is the first time that we have a formal structure to advance better health for our communities by working across all primary health care disciplines – not just General Practice.
The evidence and experience is overwhelming that the greatest opportunities to improve the health of our communities comes not from investing in more sophisticated surgical procedures, nor from block-buster drugs, nor from more hospitals, as important as these are. The greatest improvement will come from better delivery of primary care – with a focus on prevention, lifestyle improvement and risk factor reduction, systematic chronic disease management, integrated care teams, and improved patient self management.
The role of Medicare Locals then is to improve the primary care system by focusing care on the person – making sure that every person and their family can access the care that they need, when and where they need it. They will work with local primary care providers to improve the capacity and quality of their services, and will identify and close service gaps. They will also make sure that care delivery is connected, improving the experience of care for patients and clinicians.
The Medicare Locals are truly ‘local’ – owned and governed by local clinicians and the local community, and accountable to them. They are not branches of Sydney or Canberra.
The challenge that Medicare Locals face in improving the health care system should not be underestimated. For starters there are entrenched structural and funding differences across health care providers. GPs are private practitioners who receive their payments directly from Medicare. The State health system receives its funding from the State with little involvement from the Commonwealth. Other professionals receive payments from Medicare, the private health care insurers or the patient directly.
Structurally there is no imperative for these organisations to work together with Medicare Locals. What galvanises them to work with us is a shared recognition of the problems with the current systems. The currencies on which the Medicare Local will have to trade in will include relationships, trust and goodwill. Early indications are that these will be available to Medicare Locals in abundance.
North Coast NSW Medicare Local (NCML) is undertaking a major community and clinician engagement process. The decision was made to do this early so that development of the organisation’s structures are informed by what we hear.
Riding the “wave of goodwill”
We have held round table discussions and town hall style public meetings. We are encouraged by the reception we have received and the willingness of the community and clinicians to work with us.
The message and vision of strengthening Primary Health Care resonates with everyone who has attended these meetings. They see the value. Clinicians and community members came in hope that the Medicare Local structure will remedy what many recognise as major shortcomings in the healthcare delivery system.
We heard poignant and heartbreaking stories about the failure of the system. At the end of a public meeting last week, an initially sceptical clinician stood up passionately stating that he was excited and wanted to be “on board” with Medicare Local.
The challenge for Medicare Locals is to ride the wave of goodwill that exists. We have to pave the way for clinicians and community to collectively walk with us along the path of reform. The difficulties in the health sector are longstanding and complex. They require a different approach to problem solving. Often in this space even the questions are unclear, let alone the answers.
If we are interested in real long term reform, we have to listen, consult, act, reflect and learn. Through this process decisions and actions can match the local realities, local possibilities and local exigencies. There are no shortcuts or formulas to this if we are to achieve long lasting constructive change.
The key to success is that Medicare Locals are just that – “Local”. We do not have to take a state-wide or country wide view of health needs. We will assess local needs using local knowledge and local data. We will engage with local communities to understand local problems and local capabilities and we will work with local practitioners to develop locally relevant and sustainable solutions. This local focus is crucial if we are to accurately analyse the needs of the community, assess these strategically, avoid fragmentation in service design and delivery and allocate resources wisely and effectively.
Medicare Locals have no illusions about the tasks they have been given. The path to reform will not be devoid of difficulty and setbacks.
What is crucial is that Medicare Locals be given sufficient time and resources to achieve the required changes. One thing is for sure: the time is right.
The need for change is palpable and the desire for reform is universal. We are optimistic that this time the reform of the healthcare system will take place. As Victor Hugo said “nothing stands in the way of an idea whose time has come”.
 2004, Department of Health and Ageing.
 2002, AMA, Submission to the Review of the Role of Divisions of General Practice
 2007, Scott A. and Coote B.. The Value of the Divisions Network: An Evaluation of the Effect of Divisions of General Practice on Primary Care Performance.
• Vahid Saberi is CEO of the North Coast NSW Medicare Local, Adjunct Professor, School of Health & Human Science, Southern Cross University, and Senior Research Fellow, Sydney University. For the last 12 years he has had a regional leadership role in health through the NSW Health Service, most recently as General Manager of the Richmond Clarence Health Service Group. He has a strong background in strategic development, population health and planning, as well as service delivery design, and is extensively involved in research.
• Tony Lembke is Chair North Coast NSW Medicare Local Board, and a GP at Alstonville NSW. He was previously the long-serving chair of the Northern Rivers General Practice Network, and is involved in the health reform process as a director of the Australian General Practice Network, and as clinical director of the Australian Primary Care Collaboratives.
A joint policy statement from the Australian Medicare Local Alliance and Australian National Preventive Health Agency says (amongst other things) that the actions Medicare Locals will need to take to improve the health of their population include:
- designing, delivering and evaluating effective evidence-based disease prevention and health promotion interventions – at individual, group, and population levels;
- committing organisational capacity to carry out these tasks and to sustain action;
- establishing governance structures and processes that engage partners and the community (including consumers) in preventive health focused planning, capacity building, prioritisation and implementation;
- preparing population health plans that:
- profile the health of the Medicare Local population
- describe the health problems of their populations, particularly in relation to chronic disease and associated lifestyle related risks factors
- identify local issues that impact on the health of their population, including issues relating to the determinants of health. This includes social and economic infrastructure such as local governments (and their programs), schools, workplaces, transport routes, shops, banks and green space.
- developing criteria to use in selecting priorities for prevention related interventions;
- forming and sustaining effective partnerships within the health sector and between the health sector and other sectors with a view to establishing effective preventive health actions; and,
- engaging with data collection, analysis, review and feedback systems to support research, quality improvement and enable effective evaluation of prevention related services and programs.
Also available is a monograph on the evidence for preventive health and health promotion through primary care.
Oral health is the focus of the latest edition of the Health Voices Journal of the Consumers Health Forum.
An article by Tony McBride, Chair of the Australian Health Care Reform Alliance, suggests that Medicare Locals, if given the right levers, could have a crucial role in driving and facilitating oral health reform.
“The key issues here are not so much about what such services might look like: models already exist in Victoria and some other locations in Australia, and certainly overseas. Integrated services could feasibly grow from at least two directions: community health (or similar) services expanding their clientele beyond Health Care Card holders to collaborate with dentists, GPs and other allied health practices to develop new services over time serving the whole population in an area.
And similarly existing dental practices could join with other professionals, especially GPs, to create new multi-disciplinary services where teamwork, not just co-location, is encouraged. Such two-pronged development would have the added benefit of bringing the public and private dental systems closer together.”
McBride says Medicare Locals are the obvious vehicles for fostering such change. He envisages Medicare Locals eventually becoming fund holders for significant proportions of dental funding, receiving needs-based funding programs and distributing it to existing and new local services aimed at ensuring equitable access and the full range of (reasonable) needs being met.
Such an approach could also ensure a strong preventive focus and that funding does not simply encourage greater numbers of procedures without actively acting to prevent oral health disease.
This report was written by Jennifer Doggett on behalf of the AHCRA Executive, and is based on interviews with nine Medicare Local CEOs or senior managers about their early progress, the strategies they are already using and their planned objectives and approaches to primary health care reform. It aims to answer the question ‘What will Medicare Locals do and how will they do it?’
The report reveals “a high level of enthusiasm and drive within the MLs to achieve their aims. There was a genuine commitment to both genuine reform and to ongoing quality improvement of the primary health care sector.”
Most see their relationships with other stakeholders in their community as their main vehicle for driving change and so are currently focussed on developing and strengthening their local networks. All are either undertaking or planning to undertake a needs analysis of their local areas, which will form the basis of population health planning.
All the MLs interviewed expressed a strong commitment to improving access to services but had a less strong commitment to reducing inequity, partly because of perceived barriers to making a difference in this area.
The report also identifies significant barriers to MLs being able to realise their potential. It cites “three absolutely critical barriers” that need urgent attention by the Federal Government:
- the lack of clarity about the long term vision for primary health care
- MLs’ lack of power to change current policy settings (eg around predominance of fee-for-service arrangements), and
- MLs’ lack of funding levers to foster change.
The report says: “ If these factors can be addressed, in the context of a supportive funding and policy environment, AHCRA believes MLs can play a significant role in driving positive and long-term changes within Australia’s primary care sector.”
Recommendations of the report in full
Recommendation 1: The Federal Government should develop a clearer shared vision for the future of primary health care and support this with policy and funding changes to give the MLs the levers to foster change effectively.
Recommendation 2: The Government should commit to a continuation of funding for MLs for ten years (subject to reasonable performance).
Recommendation 3: Action towards achieving equitable access should be included as an (initial) key performance measure for MLs, taking into consideration the constraints on their ability to achieve gains in this area. This should be extended to indicators about improving equity once MLs have matured.
Recommendation 4: Specific training and assistance in population health planning processes should be provided to MLs, where required (for example by the Australian Medicare Local Alliance).
Recommendation 5: MLs (through the Australian Medicare Local Alliance) should liaise with experts in population health data (such as the AIHW) to establish an agreed framework for the collection and dissemination of data on their local communities.
Recommendation 6: MLs (through the Australian Medicare Local Alliance) should pro-actively seek opportunities to use the population health data collected to collaborate with other organisations on population health issues.
Recommendation 7: A framework for engagement between MLs and the Australian National Preventive Health Agency should be developed.
Recommendation 8: Key indicators on prevention activity should be included in the agreed set of performance indicators (recommended above)
Recommendation 9: Performance indicators should reflect the need for MLs to engage with consumers, carers and communities at all levels of their operations.
Recommendation 10: Coordination and integration of services at the local level should be included as key performance indicators within the performance framework agreed by government and MLs (as above)
Recommendation 11: MLs (through the Australian Medicare Local Alliance) should engage with the IHPA and the NHPA to ensure new hospital funding arrangements do not undermine the goals of MLs.
Recommendation 12: Maintaining GP engagement should be included as a key performance measure for MLs. Recommendation 13: The development of multi-disciplinary services should be included as a key performance measure for MLs over the medium to long term.
Recommendation 14: MLs and other stakeholders should have the opportunity for input into the set of performance indicators against which their performance is going to be measured.
Recommendation 15: MLs should develop a framework for sharing their experiences so that they can learn from others’ successes and failures.