At last, we have some details about how Medicare Locals are expected to work, as outlined in the previous post.
This post begins a series of commentary and analysis from Croakey contributors, which is kicked off by Professor Helen Keleher, president of the Public Health Association of Australia, and Carol Bennett, CEO of the Consumers Health Forum.
Helen Keleher calls on colleagues to work with Medicare Locals to help develop a broader vision for primary health care than that outlined by the Government, while Carol Bennett is concerned that there is not a stronger commitment to consumer involvement in decision-making and multidisciplinary care.
Let’s help broaden the focus of Medicare Locals
Helen Keleher writes:
The Australian Government’s vision for primary health care under the banner of the new so-called Primary Health Care Organisations, Medicare Locals, has finally been released.
The vision for primary health care in Australia is however, seemingly in isolation of the emphasis globally, on the relationship between the social determinants of health, equity and primary health care.
The vision of government documents seems to be about ‘reaching the unreached in primary care’. What seems to be missing is the understanding that primary health care is much more that that.
Primary health care is distinguished by vision, strategy, policy and program action to tackle health inequities through action on the social determinants of health.
Only with these dimensions can primary care become primary health care. Primary health care requires measurement of health inequities, evaluation of actions to inform the knowledge base, and the development of a workforce that is trained in the social determinants of health, and able to work in partnerships to raise public awareness about and action on the social determinants of health[i].
In economic terms, addressing health inequities has the potential to contain escalating health costs – in terms of values, addressing health equity is the right thing to do and therefore, the vision for Medicare Locals must be to do the right thing. Moreover, there is a considerable body of evidence that the social and economic circumstances of individuals and groups influence their health status and mortality more than health care itself. Social determinants of health directly effect the health of individuals and populations, and are the best predictors of both individual and population health.
What then, should be the remit of Medicare Locals, in terms of primary health care and the social determinants of health? Again, there is good evidence about the levels of action through which primary health care organisations can work to make real change to raising the health of those with the poorest health status, at a rate which is faster than that of the population as a whole.
To work at levels beyond the provision of primary care service delivery, Medicare Locals are expected to develop comprehensive population health plans. To be effective, this planning needs to include local data from a wide range of sectors from where the social determinants of health arise such as education, early childhood, women’s health, work and employment, welfare, social care and cultural agencies, local government, mental health, faith communities and other agencies which work closely with their communities.
Only with this intelligence can Medicare Locals deliver on planning to inform effective program delivery that aims to affect the social change which underpins health inequities.
The lack of explicit action to address health inequities is likely to undermine the whole purpose of Medicare Locals which is to implement comprehensive primary health care. It is beholden on those of us who care about health reform to work with local Medicare Local groups to develop their vision and strategies in spite of the lack of direction from government.
[i] Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health Final Report, 2008, World Health Organization
Why isn’t there a strong commitment to consumer involvement in decision making and multidisciplinary care?
Carol Bennett writes:
It is axiomatic that, in complex health reform, the devil is in the detail; or in the case of the Guidelines for the establishment and initial operation of Medicare Locals, issued this week, in what is left unsaid.
For health consumers, there are two critical requirements for successful applicants seeking funding for establishment of these new structures:
(1) Clear, unequivocal and detailed commitments to engagement with health consumers and the local community.
(2) A guarantee that the structure will adopt a multi-disciplinary approach to health care needs.
From our reading of the guidelines, the words used in these key areas could be best described as somewhat nebulous.
The Invitation to Apply document states: “Medical locals will reflect their local communities and health care services in their governance, including consumers, doctors, nurses, allied health and State-funded community health providers.”
They should: “identify community primary health care needs and work to fill the gaps in primary health care in their area” and “establish processes to engage effectively with patients…work with patients and the local clinical community…”
Indeed the document is literally riddled with laudable phrases about the necessity of understanding local health care need and having Board membership that “meets the needs of their community”.
Nowhere are they told of the critical importance of strong consumer input if our health services are to be improved and enhanced.
Nowhere are applicants asked to demonstrate how consumers will be involved in decision making.
There is considerable evidence that consumers bring an essential and unique perspective and can contribute to better decision-making by providing a necessary balance to the views of healthcare professionals, policy makers, business managers and researchers.
It is all too easy, as we have seen many times over the years, to offer token consumer engagement. CHF will be pressing strongly to ensure that there are unambiguous and detailed proposals from those seeking funding.
Consumers will also be concerned at the lack of detailed commitment to a multi-disciplinary approach to the provision of health care services by Medicare Locals.
Throughout the current reform process, dating back to the election of the Labor government in 2007, the constant theme has been the need for an improved, multi-disciplinary approach to health care.
In a speech to the Health Insurance Summit in 2007, the then Prime Minister Kevin Rudd said: “we will institute a reform process to provide greater incentives for GPs to practice quality preventative health care-including an increased focus on multi-disciplinary care from primary health care teams.”
In a speech in November, 2010, Health Minister Nicola Roxon said of primary health care: “It needs a skilled workforce, working together collaboratively in multi-disciplinary teams – so patients get the range of services from the range of health professionals they need, and professionals’ valuable skills are used as effectively as possible”.
CHF believes it is critical that Medicare Locals adopt a multi-disciplinary approach to providing health services.
The AMA was on the record this week reaffirming its long-held view that Medicare Locals will “only work to improve primary care if their main purpose is to support the central role of GPs in caring for patients”.
GPs play a vital role in the coordination of health care services for individuals, but they need to work with other primary health care providers in a collaborative and coordinated approach that will provide better solutions.
The Australian General Practice Network is on the record as saying it will require more money if it is to meet the objectives of the new bodies.
Once again, CHF will continue to be actively engaged to ensure that a multi-disciplinary approach is advocated and adopted by organisations applying to establish and run these new structures.
Only then will we get the better care and services for the real clients of health care – consumers.
• Stay tuned for more posts in this series…