In part two of a Croakey series analysing the Government’s plans for Medicare Locals, Professor Philip Davies, Professor of Health Systems and Policy at the University of Queensland (and a former senior federal health bureaucrat), raises a number of thorny questions facing the new organisations.
Philip Davies writes:
Divisions of General Practice and others will have welcomed the publication, on 22 February, of the Federal Government’s Guidelines for the establishment and initial operation of Medicare Locals. The Guidelines are generally clear, practical and will provide a sound basis for establishing new primary health care organisations.
The Guidelines offer long-awaited detail on the process for setting-up Medicare Locals as well as providing greater clarity on such crucial matters as the objectives Medicare locals will be expected to meet, their governance, their funding and the performance monitoring to which they’ll be subjected.
There are clear messages that Medicare Locals are to be fundamentally different to existing Divisions of General Practice and confirmation that even high-performing Divisions “will need to further develop to meet the roles and functions of a Medicare Local”.
Anyone who thought that establishing a Medicare Local was simply a matter of adding a couple of non-GPs to a Division’s Board, creating a new logo and ordering some new letterhead ought, by now, to realise that’s not the case.
The Guidelines also set out, in considerable detail, the six “selection criteria” which will be used to assess bids to become Medicare Locals. One of those, relating to “proposed governance and operational arrangements” could prove to be particularly challenging if members’ expectations are not closely aligned with Government’s intentions for Medicare Locals.
The Guidelines point out that “Medicare locals will … be accountable to both the Commonwealth and their local community”. They’re also expected (as Objective 2) to “provide support to clinicians and service providers”. Successful Medicare Locals will need to have ownership and governance arrangements that help, rather than hinder, their efforts to deliver on those accountabilities.
As Croakey has previously observed, the question of Medicare Local ownership (i.e. membership) and governance is tricky. It will ultimately be the members of a Medicare Local who get to choose at least some of its (skills-based) Board of Directors and, in keeping with the corporate model that Medicare Locals will be obliged to adopt, it will be the Board, in turn, that shapes the organisation’s strategic direction.
The Guidelines express strong preference for “organisational” rather than “individual” membership; and cite local health services and community groups as possible members. But what if some of those members became unhappy with the way the Medicare local was heading?
It’s not too hard to think of cases where that might occur.
Objective 1 in the Guidelines tasks Medicare Locals with improving access to services – but how might an organisation representing established local primary care practitioners react if that led to new services being set up which diverted patients from existing providers?
Objective 2 states that Medicare locals will be expected to “integrate varied provider types and models of care” – but how might an organisational member representing GPs react if one of those models of care involved a Government-mandated move to encourage the use of nurse practitioners or pharmacist prescribing?
Objective 3 highlights the need for Medicare Locals to “facilitate a reduction in inappropriate or inefficient service utilisation” – but what if a consumer group was a member of the Medicare Local and considered such utilisation to be both appropriate and efficient from the perspective of those whom they represent?
Objective 4 requires Medicare Locals to “coordinate the delivery of local area primary health care reform initiatives” – but what if one such initiative was to set up a Super Clinic that was perceived to benefit from Government funding and thus be competing unfairly in the local market?
And if, as the Guidelines suggest might well be the case, Medicare Locals eventually come to manage flexible funding pools for local services then members who might be in the running to deliver such services could have strong feelings about how decisions are made.
Of course the members/owners of a Medicare Local shouldn’t themselves be directly involved in decisions on such matters. They will quite rightly, expect the Board and the management of the organisation to deal with them. But it wouldn’t be beyond the bounds of possibility for disillusioned members to seek to unseat a Director whom they saw as acting against their professional, personal or (dare one say it) financial interests.
None of the above need be a barrier to the establishment and operation of highly effective Medicare Locals.
Smarter applicants will figure out ways to balance the need to ensure good governance with the legitimate role of members as representatives of those who use or deliver services. And it is to be hoped that the “selection panel consisting of officers from the Department of Health and Ageing” that assesses applications will be alert to the risks of vesting too much power in the hands of members who may from time to time face conflicts of interest.
With applications from prospective first wave Medicare locals due by 5 April, and any number of issues such as that outlined here to be addressed, it’s going to be a busy few weeks in primary care-land.
• Philip Davies is a Director of GPpartners (the former Brisbane North Division of General Practice)
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