Prominent GP reformer disappointed by delay in diabetes care overhaul

In a recent Croakey post, health policy expert Robert Wells wrote of his disappointment about the Government’s change of plans regarding reforms to diabetes care. (And his post drew a response from AMA President Dr Andrew Pesce)

The original plan was for patients with diabetes to have the option of enrolling with the general practice of their choice, with block funding for general practices for enrolled patients, and funding for allied health services to be managed by the local primary health care organisation (Medicare Local).

But Health Minister Nicola Roxon recently announced that the planned reforms (and a large chunk of the associated spending) would be deferred, pending the results of a three to four year coordinated trial due to begin next July (and following some high-profile opposition from the AMA and others).

The announcement was welcomed by the AMA and RACGP. Diabetes Australia was a touch more equivocal, saying that “while the pilot program delays the provision of the major funding on this reform, it allows the development of a program which will ultimately deliver better outcomes for people with diabetes”.

But what do others think?

The delay is disappointing

Dr Tony Hobbs, a GP from Cootamundra who chaired the external reference group of the National Primary Health Care Strategy:

I am very disappointed by the Government’s announcement to delay the implementation of the proposed reforms to diabetes care.

Three reports – from the National Health and Hospitals Reform Commission, the Preventative Health Taskforce and the Government’s own Primary Health Care Strategy – recommended an approach broadly in line with the proposed reforms. There is also considerable experience from other countries to support the potential benefits of such an approach.

I have personally been contacted by a number of colleagues from right across the field of general practice who supported the overall thrust of this reform, and who saw it as a real opportunity to improve care. Unfortunately they were largely quiet voices, and in this debate it has been the loud voices who have prevailed.

I endorse what Bob Wells wrote in his recent Croakey post. We know already there is good evidence around the benefits of voluntary enrolment for people with chronic diseases. We know that multidisciplinary team care drives improved health outcomes and this flexible funding package was a way to enable that to happen. There is some evidence, though somewhat more problematic, around outcomes-based payments go GPs. So each of those three elements of the proposed reforms was built upon pre-existing knowledge and evidence.

There were some legitimate concerns about the details of the proposed reforms but I am confident these could have been ironed out during the implementation process.

It is not clear whether the reform has been delayed because of the AMA’s opposition or because of pressures from Treasury on the health budget. In either case, it looks like an opportunity to improve the care of a significant group of patients will be, at the very least, significantly delayed.

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Trial may be useful, but don’t lose the opportunity

Professor Mark Harris, Executive Director, Centre for Primary Health Care and Equity, University of NSW

The deferral of the diabetes enrolment and block funding by the Minister appears to have been largely in response to disquiet from the profession over the quantum of funding provided for GP services and the financial risk that GPs would be taking on.

It is important that the original proposal is not lost.

This initiative was important because it represented a tentative step towards patient enrolment.  The lack of such a system has impeded optimal management of patients with chronic disease.  Up until now we had to make do with a sometimes clumsy system of gatekeeping for access to allied health based on GP Team Care plans.

A trial, while not really needed to demonstrate efficacy, may be useful in helping to illuminate a few things in the local context.  For example, it may help us to understand the costs involved in the care of patients with diabetes are and how they vary across practice populations.  This may go some way to providing better evidence about the financial “risk” and costs involved in signing up patients.

Perhaps most importantly it may also provide some clearer information on what is in it (or needs to be in it) for patients to enroll.  In NZ there was a clear benefit in terms of lower cost access to GP services.  There will need to be a benefit for patients to enroll into the scheme (over and above what they get under existing arrangements).

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Evaluation is sensible

Associate Professor Jan Barendregt, School of Population Health, University of Queensland

I’m not sure how solid the evidence is that was used to devise the original plan, but generally I support the idea of trialling such an important change first. In health service delivery this would indeed mean a trial in the Australian context, because differences in the way the health system is organised and financed would make results from, say, a US trial not really convincing.

What often happens is that a change in health services is implemented, and then afterwards an attempt is done to evaluate it. This puts the evaluators in a hard spot, because there is no comparator, and before/after compararisons are inherently weak. So you end up evaluating process and other surrogate outcomes, and firm conclusions cannot be drawn.

Given the size of the diabetes problem and the costs involved, there are very good reasons to do a solid evaluation before rushing into unknown territory.

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A note from history…

Meanwhile, here is one of the relevant sections from the National Health and Hospitals Reform Commission’s final report, June 2009:

P 256

We recommend that young families, Aboriginal and Torres Strait Islander people and people with chronic and complex conditions (including people with a disability or a long-term mental illness) have the option of enrolling with a single primary health care service to strengthen the continuity, co-ordination and range of multidisciplinary care available to meet their health needs and deliver optimal outcomes. this would be the enrolled family or patient’s principal “health care home”.  To support this, we propose that: there will be grant funding to support multidisciplinary services and care coordination for that service tied to levels of enrolment of young families and people with chronic and complex conditions; there will be payments to reward good performance in outcomes including quality and timeliness of care for the enrolled population and over the longer term, payments will be developed that bundle the cost of packages of primary health care over a course of care or period of time, supplementing fee-based payments for episodic care.

In other words, two years after the NHHRC made this recommendation, there will be a small start on trialling at least some of the proposal in one group of patients. If all goes according to schedule…

Makes you wonder, does health reform require the patience of a saint, or the steely determination of another sort of creature altogether?