Fours years ago on a sunny autumn day in Canberra, Prime Minister Kevin Rudd and NSW Premier Kristina Keneally took a stroll through the roses in the gardens of Federal Parliament. Both were bleeding political capital and desperate to do a deal to overhaul the Australian health system. Without NSW in the cart the Prime Minister could not conclude a meaningful deal within the COAG umbrella.
The compromises they made that day ensured that the inherent dysfunctions of our illness industry would keep on accumulating. Consequently, instead of an integrated unified health system, the states have kept on running hospitals, as well as many primary care functions, whilst the Commonwealth kept funding GPs. The compromises continued in setting up Medicare Locals. Their boundaries did not match the state health districts and their cooperation with the states around primary health care lacked essential governance.
For all the faults of Medicare Locals, progressive forces hoped that they would continue, but the AMA, in a churlish submission to the Horvath Review, put paid to any slim hopes of that occurring. The doctor’s peak professional body claimed that there had been a deliberate effort to down play the role of GPs, failing to take advantage of their leadership and expert understanding of primary care.
The reality is very different. The history of GPs in Australia is one of successive governments heavily subsiding the income, infrastructure and continuing professional education of primary care medicine. This has been done largely within a fee for service funding model, which might suit some GPs but has been a failure for many patients. Last year only four in 10 NSW adults who have a regular place of care reported that their GP always helps coordinate their care- a decrease of 17% from 2010. The doctors response? They just need more funding. This fails to recognise the systemic flaws in driving primary health care through a fee for service model. The red tape piles up- along with a bunch of perverse incentives and system gaming. In 2011 the World Bank reported that there was not enough evidence to justify the $2.7 billion dollars spent in the previous twelve years on a range of incentives designed to complement fee for service.
This sets the scene for Professor John Horvath’s review of Medicare Locals delivered in March this year. Professor Horvath’s credentials for conducting this review? He is certainly no expert in primary health care. Formerly a specialist renal physician, appointed by the Howard Government in 2003 as Chief Medical Officer, he is now better known as a board member of the casino gambling group – Crown. He is also Chair of the Crown Responsible Gaming Committee. (Many would think responsible gaming is a tautology)
But Professor Horvath’s most valuable credential for this review is his unabashed market fundamentalism. In his report he bluntly stated,
“I found it particularly concerning that a number of stakeholders described to me instances where Medicare Locals established services in direct competition to existing services. I consider this to be outside the Medicare Local mandate. The role of PHOs should be restricted to facilitators and purchasers and not to directly deliver service, except where there is demonstrable market failure, significant economies of scale or absence of services and patient care would be compromised.”
Professor Horvath did not trouble us with any examples. Ironically, GPs were instrumental in setting up these services. Every single Medicare Local board has a least one GP on it; and in most cases two or three doctors. This connects to the heart of the prevailing fiction that GPs are experts in primary health care. They are actually experts in their own field, namely, medicine.
A significant proportion of GPs simply want the Medicare Locals to do what the Divisions of GPs used to do; i.e., help them with credentialing, infrastructure and continuing professional education. Credit to those GPs who step forward for leadership roles. But keep in mind that they see the world through the lens of their own small business/clinical practice. To step outside this frame is like asking an independent truckie to advocate for better rail infrastructure.
Come next July, 61 Medicare Locals will morph into 30 Primary Health Networks. The current Medical Locals are busy scrambling amongst themselves to form new consortia to tender to become PHNs. There may be some surprises. Governments are probably a little weary of throwing money at models that do not deliver for patients. We might see big charities and big health insurers stepping into the ring.
Increasingly the care coordination of complex patients will be put in the hands of real experts with specific training for the role. Inevitably this will often fall to nurses and allied health professionals. Knowing the political persuasion of our government we can expect the routine high volume care coordination to be privatised/(outsourced), and the complex stuff done directly by government; a model that the poor and socially isolated should fear when we consider how this is working for the unemployed and the disabled.
Social workers, (and indeed all allied health professionals) who looked to Medicare Locals to integrate them into primary health care, have been largely disappointed. As a consequence patient care has suffered. Many Medicare Locals opted for a token allied health presence on their Boards, without a robust mechanism for consultation with fellow professionals. We have an opportunity to get it right this time around.
A good example of what is possible can be found at the Inner Western Sydney Medicare Local, which is jointly owned by three organisations; the Central Sydney Allied Health Network (CSAHN), the Central Sydney GP Network, and the Central Sydney Health Community Network. There are over 2,000 allied health professionals within the boundary of this Medicare Local, and 215 of them are members of CSAHN. This includes 85 psychologists, 33 pharmacists, 23 physiotherapists, but sadly only 8 social workers. Consider the following from the CSAHN annual report,
One of the key projects this year has been the establishment of HealthPathways Sydney to improve the patient journey and increase coordination of services. With CSAHN support, HealthPathways has been consulting with local allied health professionals to receive their input into these important pathways of care. Discipline specific HealthPathways for allied health are also being established to increase the understanding and integration of local services and appropriate referral pathways.. which will provide long lasting benefit to the local community. ..
Another significant project that we have undertaken is that of improving public/private allied health partnerships and lines of communication. All the allied health directors at the SLHD met with the CSAHN Board to discuss ways in which we could work together to create a better coordination of services and ultimately improve the patient journey. Many initiatives were agreed including joint service directories, shared CPD events, appropriate referral pathways between public and private, improved discharge reports from SLHD and shared student placements. This has been an incredibly rewarding experience working with the SLHD and something which we hope to develop further in the years to come..
Of course like the GPs, there will be many social workers and other allied health professionals who simply want to focus on their discipline specific contribution, but without local professional leadership and a strong voice they will be sidelined again.
It is now a matter of urgency to get together and get organised. Within the boundaries of each of the 30 PHNs there should be a general meeting of all allied health professionals to form an organisation committed to making real the vision of truly multidisciplinary primary health care. This kind of thinking is encompassed within the position papers of many of the health related professional associations including the AASW. The time for motherhood statements and position papers is over.
This task cannot be done from above, but all the relevant professional organisations must help by providing the connectivity, organizational tools and resources to local leaders to make this happen. Allied Health Professions Australia must set up a clearing house/coordination hub to provide local leaders with practical support for effective community action.
Coincidentally, the AASW is finally getting around to forming a national private practice committee. Involvement in this piece of work ought to be its first priority.