tag:theconversation.com,2011:/fr/topics/medicare-locals-1205/articlesMedicare locals – The Conversation2015-04-01T19:11:22Ztag:theconversation.com,2011:article/392492015-04-01T19:11:22Z2015-04-01T19:11:22ZThe debate we’re yet to have about private health insurance<p><em>In the final instalment of our series <a href="https://theconversation.com/au/topics/private-health-insurance-in-australia">Private health insurance in Australia</a>, Lesley Russell asks whether Australians need private health insurance, and what a two-tiered system means for quality, access and equity.</em></p>
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<p>The <a href="https://theconversation.com/au/topics/private-health-insurance-in-australia">six previous papers in this series</a> highlight the poorly defined role private health insurance plays in the funding and delivery of Australian health care, and how the Abbott government might allow this role to expand.</p>
<p>But major changes to Australia’s iconic Medicare system should not happen by stealth. They require full analysis and debate about whether a more integrated public-private system is a feasible option that fits with Australian values and can improve efficiency in health care financing. </p>
<p>Successive governments of both persuasions have failed to convincingly articulate why Australians need what is increasingly a duplicate health care system – with duplicate costs for many – and why the federal financial contribution to private health insurance should be so substantial. The <a href="http://www.budget.gov.au/2014-15/content/bp1/html/index.htm">2014-15 Budget Papers</a> show the cost of the private health insurance rebate will grow from A$5.997 billion in 2013-14 to A$7.187 billion by 2017-18. </p>
<p>Private health insurance is variously seen as an essential feature of a “balanced” health care system comprising both publicly and privately funded and provided health care, or as an instrument of patient choice and responsibility that relieves the pressures in increasingly strained public services. </p>
<p>Most recently, the <a href="http://www.ncoa.gov.au/report/phase-one/recommendations.html">National Commission of Audit</a> (NOCA) has raised the possibility of requiring higher-income earners to take out private health insurance for basic health services in place of Medicare. Both the NCOA and the <a href="http://competitionpolicyreview.gov.au/files/2015/03/Competition-policy-review-report_online.pdf">Harper Competition Policy Review</a> advocate an expanded role and less regulation for the private health insurance sector.</p>
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Read more:
<a href="https://theconversation.com/allow-aussies-to-opt-out-of-medicare-and-rely-on-private-health-insurance-38647">Allow Aussies to opt out of Medicare and rely on private health insurance</a>
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<p>These are ideological arguments and much of the dilemma facing those who would work to implement effective policy in this area is the dearth of information about what drives people to purchase health insurance and to use it.</p>
<p>Since 1999 a <a href="http://theconversation.com/private-health-insurance-means-test-passes-what-now-5356">raft of government initiatives</a> – financial carrots and sticks – have aimed to encourage more Australians, especially those who are better off, to purchase private health insurance. </p>
<p>For the most part, these were not evidence-based and consequently have had little or no impact. Only the Lifetime Health Cover Loading and the “run for cover” campaign <a href="http://www.researchgate.net/publication/4998560_Response_Run_for_Cover_Now_or_LaterThe_impact_of_premiums_threats_and_deadlines_on_supplementary_private_health_insurance_in_Australia">had an impact</a> and this has been interpreted as a response to a deadline and an advertising blitz, rather than a pure price response. </p>
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Read more:
<a href="https://theconversation.com/private-health-insurance-carrot-and-stick-reforms-have-failed-heres-why-38501">Private health insurance 'carrot and stick' reforms have failed – here's why</a>
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<p>University of Adelaide economist Terence Cheng has <a href="https://www.melbourneinstitute.com/downloads/policy_briefs_series/pb2013n03.pdf">estimated</a> the price elasticity of demand and found that a 10% increase in premiums would result in a reduction in private health insurance coverage of less than 2%. So most Australians who have private health insurance would retain it even if the rebate was completely dropped.</p>
<p>The prevailing wisdom is that people purchase private health insurance to have their choice of doctor and hospital facilities, but as <a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">researcher Sophie Lewis and her colleagues at the University of Sydney</a> have found, it is really more about shorter wait times for hospital procedures, perceived quality of care and “peace of mind”. </p>
<p>Having private health insurance provides the ability to “jump the queue” to access a range of elective procedures in private hospitals. But this comes at a price for all patients. </p>
<p>People with private health insurance are likely getting services ahead of people without insurance but with greater need. The private patient who gets their orthopedic or cataract surgery within weeks rather than months will very often end up with substantial, unexpected out-of-pocket costs. </p>
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Read more:
<a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">Explainer: why do Australians have private health insurance?</a>
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<p>Contrary to government claims, the increase in services delivered in private hospitals has <a href="https://theconversation.com/private-health-insurance-carrot-and-stick-reforms-have-failed-heres-why-38501">done nothing to ease</a> the pressure on public hospitals and in fact waiting times for urgent procedures in public hospitals has increased. </p>
<p>Private health insurance does not buy extra quality and safety either. The <a href="http://www.pc.gov.au/inquiries/completed/hospitals/report/hospitals-report.pdf">Productivity Commission</a> found that the larger, most comparable public and private hospitals have similar adjusted premature death ratios. And team-based care in large public hospitals means better care coordination.</p>
<p>The peace of mind that private health insurance is supposed to bring is very often illusionary. Sometimes it’s the realisation that certain procedures or prostheses are not covered; more often it’s the shock of unexpected out-of-pocket costs. More than 20% of private care is paid for by <a href="http://phiac.gov.au/wp-content/uploads/2014/10/PHIAC-Annual-Report-2013-14.pdf">patients’ out-of-pocket costs</a>, which in 2014 averaged A$285 per hospital episode.</p>
<p>The mix of levies, surcharges and rebates – and funds that constantly change their policies – make it difficult for even astute consumers to judge the true cost and value of their private health insurance. </p>
<p>In fact, many people <a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">know little</a> about the policy they purchase – what it covers, how much it covers, whether it is good value and suited to their needs. </p>
<p>The Commonwealth government’s decision to subsidise private health insurance means it has a substantial financial stake in the private sector alongside its existing stake in the public sector. However, while there are incentives to encourage the purchase of private health insurance, there is no requirement for it to be used. </p>
<p>About a quarter of people with private health insurance choose to <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4839.0.55.0012009">use the public system</a>. Therefore, a significant proportion of the private health insurance rebate is effectively wasted as people purchase cover for financial rather than health reasons.</p>
<p>Public policy experts <a href="https://cpd.org.au/wp-content/uploads/2012/01/CPD_DP_Menadue_McAuley_PHI_2012.pdf">Ian McAuley and John Menadue</a> have made the case that private health insurance is an expensive and clumsy way to do what the tax system and Medicare does better: distribute funds to those who need health care and the effective management of health care costs. </p>
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Read more:
<a href="https://theconversation.com/if-the-government-wants-price-signals-it-should-stop-supporting-health-insurance-38389">If the government wants price signals, it should stop supporting health insurance</a>
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<p><a href="http://www.oecd.org/els/health-systems/33698043.pdf">International evidence</a> shows that private health insurance decreases cost controls and it <a href="http://johnmenadue.com/blog/?p=2884">has been argued</a> that gap insurance has underwritten the dramatic growth in specialist fees. Further, pushing higher income earners (who generally have better health) to take out private health insurance, and then increasingly prejudicing access to services in their favour ensures a <a href="http://www.euro.who.int/__data/assets/pdf_file/0007/96433/E89731.pdf">widening of existing health disparities</a>.</p>
<p>In the absence of a clearly stated and managed role for private health insurance – either as competitor or collaborator – it is effectively undermining the power of Medicare as a single payer and the role of Medicare as a universal provider. This situation is predicted to unravel further, as the Abbott government <a href="http://www.news.com.au/national/private-health-insurers-set-to-manage-patients-gp-care/story-fncynjr2-1227031109206">signaled</a> its agenda to allow private health insurance to play an expanded role in primary care. </p>
<p>Some of larger funds are already expanding their activities in this sector, but with little oversight. </p>
<p>Last year Medibank Private began a program in Queensland that guarantees Medibank members same day GP appointments, fee-free care, after-hours GP visits and a range of health assessments. Medibank <a href="http://www.smh.com.au/business/medibanks-first-numbers-from-gp-trial-20141016-1175sp.html">claims</a> the trial is operating within the bounds of the law because it pays only for administrative costs, as opposed to funding the doctors directly. </p>
<p>The concerns this raises about the generation of a two-tiered health system are further fuelled by the possibility that private health insurance funds were <a href="http://www.news.com.au/national/private-health-insurers-set-to-manage-patients-gp-care/story-fncynjr2-1227031109206">eligible to tender</a> to run the new Primary Health Networks.</p>
<p>It’s an indictment of the passivity of federal government policymakers that private health insurance funds are more willing to kick start the innovative initiatives that are needed to deliver more proactive preventive care, better care coordination and a greater focus in health outcomes. </p>
<p>It’s more troubling that these initiatives are currently occurring in a policy vacuum with a narrow focus on solutions led by the funds for the benefit of their members. This will not assist the millions of Australians who don’t have private health insurance and could have a major impact on the equity and efficiency of the health care system and the budget bottom line.</p>
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<p><em>If you missed any <a href="https://theconversation.com/au/topics/private-health-insurance-in-australia">Private Health insurance in Australia</a> articles or our <a href="https://theconversation.com/infographic-a-snapshot-of-private-health-insurance-in-australia-39237">infographic</a>, visit the <a href="https://theconversation.com/au/topics/private-health-insurance-in-australia">series page</a>.</em></p><img src="https://counter.theconversation.com/content/39249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the final instalment of our series, Lesley Russell asks whether Australians need private health insurance, and what a two-tiered systems means for quality, access and equity.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/363462015-01-20T19:25:36Z2015-01-20T19:25:36ZThe AMA and Medicare: a love-hate relationship<p>The Australian Medical Association (AMA) has emerged from the recent brouhaha over the Abbott government’s proposed Medicare reforms as both a winner in the protection of doctors’ incomes and an apparent champion of the affordability of health care for patients. </p>
<p>Medicare changes that were due to come into effect this week would have imposed a ten-minute minimum for regular (Level B) GP consultations, which currently attract a A$37.05 rebate. Consultations under ten minutes would have attracted a smaller rebate of A$16.95. GPs were faced with a choice: absorb the cuts or pass them on to patients. </p>
<p>The AMA <a href="http://www.smh.com.au/federal-politics/political-news/patients-face-new-20-fee-for-seeing-their-gp-20150112-12mpag.html">framed the change</a> as a A$20 cut to patient rebates for short visits and used data to dismiss government claims of “six-minute medicine”. </p>
<p>The proposals drew widespread public condemnation. When the opposition vowed to disallow the regulations implementing the cut when the Senate resumed in February, the government was left with little choice but to abandon the plan days before it was due to take effect. </p>
<p>It was an effective demonstration of the power and profile of the AMA, using a potent combination of evidence and scare tactics. </p>
<p>Now the real work begins for the new health minister, Sussan Ley, the cabinet and all the stakeholders in Medicare. The AMA is (rightly) guaranteed a place at the consultation table, but others are equally entitled to be there – including other professional medical groups, a wide range of primary care workers, pharmacists, aged care and mental health representatives and consumer and patient organisations. </p>
<p>Students of the history of Medicare are entitled to expect that in the upcoming negotiations the AMA will revert to standard practice, crowding out others and zealously safeguarding turf, <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">fee-for-service</a> and doctors’ incomes. </p>
<p>But the definition of a successful resolution to the current impasse does not lie solely with an agreement between the health minister and the AMA; the problems to be addressed are much broader than an adequate reimbursement for Medicare services provided through general practice. </p>
<p>The AMA has a tradition of opposing key health reforms, good and bad, dating back to the 1940s when the <a>Pharmaceutical Benefits Scheme</a> (PBS) was introduced. The AMA (then an offshoot of the British Medical Association) opposed the PBS with unrelenting vigour. </p>
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<img alt="" src="https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/69468/original/image-20150120-14495-wf1obq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The then-BMA opposed socialised medicine and tried to block the PBS.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-242820400/stock-photo-operation-at-provident-hospital-chicago-illinois-in-showing-increased-use-of-antiseptic.html?src=dVcPYQBy5NwU4QfItBVyjA-1-11">Everett Historical/Shutterstock</a></span>
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<p>Robert Menzies, then leader of the opposition, agreed to support the government’s case. But the price for this, extracted by the BMA, was a referendum question to <a href="http://www.jstor.org/discover/10.2307/40111513?sid=21105657425573&uid=3737536&uid=2&uid=4">change the constitution</a> to prohibit any form of civil conscription, thus effectively making socialised medicine forever impossible. </p>
<p>Similarly, the AMA met the introduction of <a href="http://www.aams.org.au/contents.php?subdir=library/history/funding_prof_med_au/&filename=index">Medibank and later Medicare</a> with ferocious opposition, although it was not alone – many in the medical professions, the General Practitioners’ Society and the private health funds were also against these reforms. Opponents argued that the system constituted a socialist takeover of medicine that would limit their incomes and the freedom of Australian citizens. </p>
<p>Fortunately, the AMA eventually agreed that perhaps there were some benefits to publicly subsidised health care. No AMA spokesperson today would advocate the abolition of these programs. And in fairness, on the other side, <a href="http://www.theage.com.au/articles/2003/12/31/1072546587433.html?from=storyrhs">cabinet documents</a> released some years ago revealed that the Whitlam government had its own – largely irrational – fears that doctors would treat Medibank as a licence to print money, by over-servicing patients, knowing the government would foot the bill.</p>
<p>These confrontations occurred decades ago, but they highlight deep-rooted suspicions on the part of both the AMA and government about each other’s value systems that still linger, mostly hidden, but emerging regularly. Last week, the AMA described the proposed reimbursement changes for level B consultations as “an assault on general practice”, while Liberal Party backbencher Andrew Laming called for a crackdown on “cowboy doctors”. </p>
<p>It is increasingly clear that Tony Abbott and his government are not the “<a href="http://www.abc.net.au/news/2014-02-20/tony-abbott-says-coalition-medicare-best-friend/5272376">best friend that Medicare has ever had</a>” and the Coalition’s preferred position would be a Fraser-government-style retreat on publicly funded health care, leaving Medicare as an increasingly ragged safety net for the poor. So there are no great expectations for real reforms to emerge from the promised consultations, despite the strong case for change.</p>
<p>In recently published articles with colleagues <a href="https://www.scribd.com/doc/252087121/05-01-2015-Tackling-OOP-Costs">Jennifer Doggett</a> and <a href="https://www.mja.com.au/insight/2015/1/lesley-russell-stephen-leeder-rough-road">Stephen Leeder</a>, I have outlined the need to focus on delivering increased value and quality in health care, how growing out-of-pocket costs are arguably leading to increased hospital costs, and the need for more teamwork and connected and coordinated care. </p>
<p>Reforms are needed to address these and other problems, including:</p>
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<li>years lost needlessly to disability</li>
<li>growing health disparities in some population groups</li>
<li>a health workforce that does not reflect current and future needs in its make-up and distribution</li>
<li>outdated reimbursement methods</li>
<li>a failure to direct spending to ensure improved long-term health outcomes and economic sustainability. </li>
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<p>Will the AMA be an effective protagonist for these issues in the upcoming discussions and negotiations? </p>
<p>On the one hand the AMA has an <a href="https://ama.com.au/advocacy/position-statements">outstanding record</a> as an advocate for issues as important and varied as the social determinants of health, climate change, asylum seekers’ health, problem gambling, violence against women and rural health. Most years over the past decade have seen the production of an <a href="https://ama.com.au/advocacy/indigenous-health">Indigenous health report card</a> and the AMA has used its resources to highlight the need to close the gap on Indigenous disadvantage and to encourage Indigenous doctors. </p>
<p>On the other hand, the AMA has generally opposed Medicare reforms at their introduction, regardless of political parenthood. AMA panned <a href="https://ama.com.au/media/fairer-medicare-package-not-answer">Fairer Medicare</a>, <a href="https://ama.com.au/media/medicare-plus-positive-second-best-option">Medicare Plus</a>, <a href="https://ama.com.au/media/gp-super-clinics-not-so-super-ama">GP Super Clinics</a>, <a href="https://ama.com.au/ausmed/govt-told-think-gp-medicare-locals">Medicare Locals</a> and <a href="https://ama.com.au/ausmed/governments-diabetes-plan-gps-say-no-thanks">coordinated care for diabetes</a>. Its support for bulk billing has been lacklustre at best, although the AMA has <a href="https://ama.com.au/submission/submissions-out-pocket-costs-australian-healthcare">spoken out</a> about the impact of out-of-pocket costs.</p>
<p>The AMA has campaigned aggressively around <a href="https://ama.com.au/media/doctors-fight-back-soaring-indemnity-costs">medical indemnity costs</a>, <a href="https://ama.com.au/ausmed/governments-diabetes-plan-gps-say-no-thanks">managed care programs</a>, <a href="https://ama.com.au/media/ama-applauds-decision-scrap-cap">Scrap the Cap</a> on work-related self-education expenses for professionals, <a href="https://ama.com.au/media/ama-calls-commonsense-prevail-cataract-surgery-senate-standoff">reduced reimbursements</a> for cataract surgery, the <a href="https://ama.com.au/media/ama-questions-safety-pharmacy-vaccinations">provision of immunisation</a> and other services in pharmacies, and the ability of <a href="https://ama.com.au/media/optometry-board-puts-glaucoma-patients-care-risk">optometrists to manage</a> glaucoma patients. </p>
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<img alt="" src="https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/69474/original/image-20150120-22679-11eadm3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">An astute minister will consult widely to ensure all doctors’ voices are heard.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6869336880">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
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<p>Basically the AMA is very good at doing what most unions do: protecting members’ income and interests. In health policy terms this boils down to two basics: <a href="https://ama.com.au/media/ama-speech-ama-president-aprof-brian-owler-private-healthcare-australia">fee-for-service as the gold standard</a> for reimbursement and aggressive turf protection as non-medical health professional boards look to <a href="https://ama.com.au/media/ama-takes-strong-stance-non-medical-prescribingple.com/">expand their scope of practice</a>. </p>
<p>Given the growing recognition that fee-for-service encourages volume over value and that primary health care is about more than general practice, there will eventually be showdowns on these issues, even if they are not on the table this time around. </p>
<p>It is important to realise that there are <a href="http://blogs.crikey.com.au/croakey/2010/04/07/the-ama-says-its-the-chief-health-policy-advisor-really/?wpmp_switcher=mobilhttp://example.com/">many Australian doctors</a> who do not see their interests as well represented by the AMA (only about 40% of Australian doctors are AMA members), so an astute health minister will consult more widely to ensure that all doctors’ voices are heard, along with those of other health professionals and – most importantly – the patients. </p>
<p>The AMA is just one of the keys to unlocking an effective resolution to the current health and budget impasse.</p><img src="https://counter.theconversation.com/content/36346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Australian Medical Association (AMA) has emerged from the recent brouhaha over the Abbott government’s proposed Medicare reforms as both a winner in the protection of doctors’ incomes and an apparent…Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/301442014-09-03T20:16:58Z2014-09-03T20:16:58ZCreating a better health system: lessons from England<figure><img src="https://images.theconversation.com/files/58059/original/4mbb5kgd-1409707554.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the UK, surgeries are awarded points and additional funding for keeping patients healthy.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/worldlifephotography/502291942">emanueletudisco photography/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p><em>Australia has a relatively strong health system by international standards, but it needs a makeover. To generate fresh ideas, The Conversation is <a href="https://theconversation.com/uk/topics/international-health-systems">profiling five international health systems</a> that have important lessons – good and bad – to pull Australia out of its health reform black hole.</em></p>
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<p>While Australia and England share much of their cultural heritage, the countries have answered the challenge of funding health care in quite different ways. </p>
<p>The Australian <a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Medicare</a> system is predominantly based around private practice and fee-for-service. The English National Health System (NHS) is based on capitation, in which doctors are paid a fixed amount to manage a group of potential patients irrespective of the actual level of care.</p>
<p>Neither system is perfect, but each can learn from the other; after all, they both aim to achieve efficient, equitable, high-quality health services is the same. </p>
<h2>Fee-for-service vs capitation</h2>
<p>Australia’s emphasis on fee-for-service funding reflects both a strength and weakness. Paying for each consultation or service, mainly through the <a href="http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Medicare-Benefits-Schedule-MBS-1">Medical Benefits Schedule</a>, incentivises doctors to do more. </p>
<p>But it can also lead to over-provision of care. Most of us have anecdotes about returning to the doctor for procedural issues, such as renewing prescriptions, or receiving test results, which might be more efficiently done over the phone, or by a nurse or pharmacist.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58054/original/dw2kz422-1409705900.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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</figure>
<p>The English system, with its focus on capitation, may be too far in the opposite direction. Under capitation, doctors are paid an amount to manage a set of patients, this amount usually determined by estimates of need. </p>
<p>If doctors are effectively paid no extra for providing additional care to a patient, then you can reasonably expect an average level of service below what is optimal. </p>
<p>Both the English and Australian systems have tried various ways of blending fee-for-service and capitation, but the two systems continue to sit some distance apart. </p>
<h2>Pay for performance</h2>
<p>One possible way out of this impasse is to move towards a system in which doctors are paid for results, rather than activity.</p>
<p>The English system has considerable experience in this area – good and bad – with its Quality and Outcomes Framework (<a href="http://www.hscic.gov.uk/qof">QOF</a>), which attempts to pay doctors directly for their patients’ health outcomes. </p>
<p>Under this system, surgeries are awarded points for a range of outcomes including chronic disease management, practice organisation, positive patient experience, and the provision of extra services such as child health and maternity services. These points are then translated into a financial payment for the surgery. </p>
<p>In England, there is mixed evidence about the appropriateness of this system. Design has proven a major challenge; in the first year, there was a cost blowout as surgeries achieved a <a href="http://www.bmj.com/content/331/7520/800.1.full">much higher proportion</a> of points than was expected. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58055/original/dk3hqrvh-1409706002.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
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</figure>
<p>So, could such an approach be taken in Australia? </p>
<p>The answer is that it would be difficult. Patients are registered to surgeries in England, meaning it’s easier to link clinical outcomes with the activity of particular doctors. </p>
<p>But Medicare data <em>does</em> show us which patients see which doctors, so linking to outcomes might be feasible in Australia. </p>
<p>However, as with much of the area of international transferability of health policy, the basic policy idea would need to be adapted to reflect the existing health system architecture.</p>
<h2>Keeping people out of hospitals</h2>
<p>Over the past decade, the English health system has pursued a policy of local commissioning of services. Led by local GPs, <a href="http://www.patient.co.uk/doctor/clinical-commissioning-groups-ccgs">Clinical Commissioning Groups</a> (CCGs) are responsible for allocating their local community’s health budget on emergency care, elective hospital care, maternity services and community mental health services. </p>
<p>CCGs place general practitioners at the heart of health care funding decisions, giving them a role previously undertaken by lay managers in primary care. </p>
<p>The aim is to strengthen primary care and keep people out of hospitals. If you make one body responsible for purchasing primary care (such as GPs) and secondary care (predominantly hospitals), you’re likely to make better use intensive GP interventions that would reduce the use of considerably more expensive hospital care. </p>
<p>In the <a href="http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted">2012 Health and Social Care Act</a>, the Conservative-led coalition placed £65 Billion into the hands of 211 newly-formed CCGs, 65% of a total NHS budget of £95 Billion. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58060/original/gszft9y5-1409707781.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">CCGs account for two-thirds of England’s NHS budget.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-74383099/stock-photo-morning-commuters-in-london.html?src=VHTKQPBvMfuPT8CfV5Oy7g-1-23">r.nagy/Shutterstock</a></span>
</figcaption>
</figure>
<p>The English experience of commissioning is still a developing story. It appears to offer benefit, but the design of the system is crucial. Those doing the local commissioning must be supported both logistically and financially, so they have the <a href="http://www.nuffieldtrust.org.uk/publications/clinical-commissioning-groups-supporting-improvement-general-practice">time to dedicate</a> to this work and it <a href="http://www.hsj.co.uk/news/commissioning/exclusive-over-60-per-cent-of-ccgs-choose-pct-manager-as-their-leader/5042683.article#.U-A032MvjDM">isn’t just passed on</a> to bureaucrats. </p>
<h2>Australia’s fragmented system</h2>
<p>Our health system is funded from a mixture of state/territory and federal money. Primary care is predominantly paid for by Medicare, while much of the financial cost of providing hospital care is met by the states and territories. </p>
<p>This poses a major problem for health-care reform. There is an incentive for both the states and the federal government to shift costs towards the other, which can be easily done by moving patients between primary and secondary care. </p>
<p>Further, the incentive to keep people out of hospital by providing more high-quality primary care is weak, because the government level responsible for primary care (federal) does not reap any savings from this extra investment. </p>
<p>Community-level organisations such as Medicare Locals are being given small pockets of funding to commission locally, and it is likely that this role will be included in the new <a href="http://www.nuffieldtrust.org.uk/talks/slideshows/holly-holder-clinical-commissioning-groups-one-year">Primary Health Networks (PHNs)</a> when they replace Medicare Locals.</p>
<p>One option is to give local commissioners more power through the PHNs and redirect some state government funding directly to the community-based organisations. </p>
<p>But caution is required, as English history demonstrates high-quality commissioning requires substantial time and financial investment, as well as effective leadership and the willingness of clinicians to engage. </p>
<h2>Designing a better health system</h2>
<p>Like most other countries, Australia cannot continue to fund the increasing demand for health care, and we need to look for ways to strengthen the role of primary care and keep people out of hospital. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58061/original/p9sf36g6-1409708290.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Australia needs new policies to keep people healthy and out of hospital.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-173822594/stock-photo-waiting-room.html?src=MkaPqgXGo1WXRXfhl1HMVw-3-15">Image Point Fr/Shutterstock</a></span>
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</figure>
<p>In the endless debate around how to pay doctors in a way that doesn’t cause over- or under-servicing, adding payments for keeping people healthy is one possibility Australia should consider. But we need to keep in mind the possible negative consequences of such a policy. </p>
<p>Similarly, Australia should consider supporting local clinicians to make decisions that benefit their community. But because our health systems are so structurally different, the design of such a system for Australia would be a challenge requiring considerable thought.</p>
<p><strong>This article is part six of The Conversation’s <a href="https://theconversation.com/uk/topics/international-health-systems">International Health Systems</a> series. Click on the links below to read the other instalments.</strong></p>
<ul>
<li><a href="https://theconversation.com/what-can-we-learn-from-other-countries-health-systems-30885">What can we learn from other countries’ health systems?</a></li>
<li><a href="https://theconversation.com/creating-a-better-health-system-lessons-from-the-netherlands-30270">Creating a better health system: lessons from the Netherlands</a></li>
<li><a href="https://theconversation.com/creating-a-better-health-system-lessons-from-singapore-30607">Creating a better health system: lessons from Singapore</a></li>
<li><a href="https://theconversation.com/creating-a-better-health-system-lessons-from-norway-and-sweden-30366">Creating a better health system: lessons from Norway and Sweden</a></li>
<li><a href="https://theconversation.com/creating-a-better-health-system-lessons-from-the-united-states-30266">Creating a better health system: lessons from America</a></li>
<li><a href="https://theconversation.com/infographic-comparing-international-health-systems-30784">Infographic: comparing international health systems</a></li>
<li><a href="https://theconversation.com/australian-health-care-where-do-we-stand-internationally-30886">Australian health care: where do we stand internationally?</a></li>
</ul><img src="https://counter.theconversation.com/content/30144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Norman receives funding from the NHMRC and ARC.</span></em></p><p class="fine-print"><em><span>Suzanne Robinson receives funding from Curtin University</span></em></p>Australia has a relatively strong health system by international standards, but it needs a makeover. To generate fresh ideas, The Conversation is profiling five international health systems that have important…Richard Norman, Senior Research Fellow in Health Economics, Curtin UniversitySuzanne Robinson, Associate Professor of Health Policy and Management, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/269152014-05-20T20:19:46Z2014-05-20T20:19:46ZAlready fragile, rural health set to suffer more under the budget<figure><img src="https://images.theconversation.com/files/48971/original/7f8nwxfy-1400565543.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lack of local professionals means rural health is already under pressure and the budget will only make things worse. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mythoto/2192420810">Len Matthews/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>People living in remote and rural Australia already have a <a href="https://theconversation.com/unravelling-why-geography-is-australias-biggest-silent-killer-23238">shorter life expectancies and higher rates of premature deaths</a>. Last week’s federal budget will not only make that worse, it will introduce even more problems. </p>
<p>Let me explain with an example of what the budget means for one region. I live in rural New South Wales and lead a university department located in a large rural town with a Base Hospital. </p>
<p>There are 120 general practitioners who work in our rural valley and offer after-hours services. These doctors work hard to keep low-income people in their practices; despite advertising fees above the bulk-billing rate, 85% only charge many clients the Medicare rebated fee. </p>
<p>The viability of continuing to subsidise this clientele was already worrying these doctors. Many of them have clinics that employ practice nurses and other general practitioners, and their income is insufficient to continue to do this as well as subsidise poorer patients. </p>
<p>The introduction of the co-payment for visiting doctors will increase the number of local people who don’t seek care from a GP. This will damage their health and the viability of these rural medical centres.</p>
<h2>Bad to worse</h2>
<p>For the past 12 months, the Medicare Local in our area had provided services for rurally located vulnerable people without a doctor. Despite this effort 20% of the children admitted to the local hospital do not have access to family medical services.</p>
<p>These children – and their parents – do not have the benefit of a GP to implement prevention, early intervention and low acuity care. Nor do they receive general practice care after discharge from the local hospital. </p>
<p>People deterred by the GP co-payment to seek primary care will end up in our hospital’s emergency department. It’s likely these people will be considerably more ill by the time they get to hospital.</p>
<p>Our very busy Base Hospital is <a href="http://www.farnorthcoaster.com.au/news/2608/north-coast-area-health-under-funded-by-70m-inquiry/">already underfunded</a> by about $70 million a year. It’s likely to be further overextended as cuts to the health budget are felt – and it faces the prospect of more ambulance callouts and people needing help in its emergency department.</p>
<h2>Not untypical</h2>
<p>People in rural areas with poor primary health care are more likely than those in cities to end up in hospital. There’s evidence for this in a <a href="http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_PAH_Report_November_2013.pdf">2012 National Preventative Health Agency (NPHA) report</a> that examined 21 causes of avoidable hospitalisations. Two of these are often suffered by children - vaccine-preventable disease and asthma. </p>
<p>Not only does the countryside suffer from a dearth of GPs, community nurses, pharmacists, dentists and allied health practitioners are also rare. And parents and others are stuck in a vicious cycle, because the lack of post-hospital care leads to another hospital admission and so on.</p>
<p>As shocking and distressing as this is, it’s not unusual in rural parts of this country. Our local hospital draws from a typical regional population, which has higher than urban rates of <a href="http://ruralhealth.org.au/document/snapshot-poverty-rural-and-regional-australia">poverty and chronic illness</a>. </p>
<p>Much of our population lives in small communities or towns that cannot sustain a general practitioner, pharmacist or allied health worker. Transport is difficult for many; cars may be shared but petrol is already expensive. And transport is about to become even more costly because of the decision to restore indexation of federal petrol excise.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=905&fit=crop&dpr=1 754w, https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=905&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/48988/original/m9ztdb2z-1400572245.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=905&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In a 12-month period North Coast NSW Medicare Local (NCNSWML) provided extensive clinical services where there was a gap and unmet need.</span>
<span class="attribution"><span class="source">NCML</span></span>
</figcaption>
</figure>
<p>Rural areas have less private health insurance coverage, fewer private practitioners and private hospitals. </p>
<h2>Other measures</h2>
<p>A number of other budget measures will also affect us disproportionately. The Australian Institute of Health and Welfare - about to become part of the mega National Productivity and Performance Authority, along with five other currently independent bodies - provides us with data that illustrates the inequality of rural and remote health services. </p>
<p>It may lose its autonomy and focus and become subject to political influence. </p>
<p>The National Preventive Health Agency, also to be brought into the health department, is particularly important to rural health. Prevention strategies are sorely needed to address things like the higher rates of smoking in rural areas and <a href="https://www.mja.com.au/journal/2013/199/1/how-will-we-close-gap-smoking-rates-pregnant-indigenous-women">these need to be different</a> from what’s done in the city.</p>
<p>Our Medicare Local will be replaced with a possibly larger new primary health organisation. It already covers 35,570 square kilometres, four regional centres, and 30 towns – that’s 495,549 people. To extend this further means its capacity to be responsive and integrate acute and primary care will become impossible.</p>
<p>Families living in rural and remote areas are already struggling to have good health. This budget means they will suffer even more inequitably compared with other Australians.</p>
<p><strong><em>Correction:</em></strong> This article has been amended to say the AIHW will become part of the National Productivity and Performance Authority. The original incorrectly stated that it would become part of the Department of Health.</p><img src="https://counter.theconversation.com/content/26915/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Barclay receives funding from the National Health and Medical Research Council. She directs the University Centre for Rural Health in northern NSW which is part of Sydney University, is the Deputy Chair of the National Rural Health Alliance and sits on the Boards of the Local Health District and the Medicare Local.</span></em></p>People living in remote and rural Australia already have a shorter life expectancies and higher rates of premature deaths. Last week’s federal budget will not only make that worse, it will introduce even…Lesley Barclay, Professor of Rural Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/220082014-01-20T19:36:12Z2014-01-20T19:36:12ZLet Medicare Locals find their feet and improve primary care<figure><img src="https://images.theconversation.com/files/39411/original/5smp52jt-1390197823.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicare Locals plan for better, tailored health services by drawing on local knowledge.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>Primary health care in Australia is a messy beast, with many heads and all sorts of body parts. But it’s centrally important because it plays a <a href="http://theconversation.edu.au/have-medicare-locals-been-set-up-to-fail-6678">major role</a> in achieving public health outcomes, such as better co-ordinated care for people with chronic conditions, good immunisation rates and programs to help people quit smoking and lose weight. Medicare Locals (MLs) now have a role in coordinating and improving this care, but their future is unclear. </p>
<p>MLs were set up during the Rudd-Gillard health reforms to tame the beast, plan for better preventive health, fill gaps in service and improve coordination by drawing on local knowledge. This means working with hospitals, Aboriginal medical services, community health services, patient advocacy groups, the aged, refugees and immigrants, as well as state and local governments. </p>
<p>Before the election, health minister Peter Dutton derided MLs as merely an “extra layer of bureaucracy”, <a href="https://theconversation.com/give-medicare-locals-a-chance-to-improve-health-equity-12965">foreshadowing the possibility</a> they could be axed under a Coalition government. Professor John Horvath, chief medical officer from 2003 to 2009, is now <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2013-dutton025.htm">reviewing</a> the role and function of MLs. Submissions closed last month and he will report to government in March.</p>
<p>There are 61 Medicare Locals across the country, the first of which have been operating for a little over two years. Since MLs have now <a href="http://amlalliance.com.au/policy-and-advocacy/policy-sumissions">provided</a> more than 500,000 services and 4,700 professional development and education sessions for health professionals, it will take more than a click of the fingers to cut them out and return to the pre-2011 system where the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pcd-programs-divisions-index.htm">Divisions of General Practice</a> did some (but nowhere near all) of this work.</p>
<h2>Submissions to the review</h2>
<p>There are many more services and providers involved in Medicare Locals than general practitioners and specialists, though listening to some of the dominant voices involved in the review gives the opposite impression. </p>
<p>Disappointingly, the submission of the <a href="https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&ved=0CDsQFjAD&url=https%3A%2F%2Fama.com.au%2Fsystem%2Ffiles%2Fama_submission_to_review_of_medicare_locals.pdf&ei=gfLEUs_qCZGElAWY8oCICg&usg=AFQjCNHFLV-9vIIk3-89FtiZNh4aeENU_g&bvm=bv">Australian Medical Association</a> (one of the doctors’ advocacy groups with a big voice in policy debates) takes the simple view that Medicare Locals don’t work because they are not dominated by doctors. The AMA role is to protect the earnings and interests of doctors but its submission is a thin piece of analysis referring to none of the successes, strengths or potential of MLs.</p>
<p>On the other side, the <a href="http://amlalliance.com.au/policy-and-advocacy/policy-sumissions">submission</a> from the Australian Medicare Local Alliance is all sunshine and flowers. It gives a very positive set of reasons to give MLs a longer go and is thin on the real criticisms that may have to be addressed. Helpfully, it attaches appendices with some statistics and many examples of the work and success stories so far. The Greater Metro South Brisbane Medicare Local, for instance, has offered 11 <a href="http://www.gmsbml.org.au/Health-Professionals-Services-Optimal-Health-Self-Management.php">Chronic Disease Self-Management Programs</a> to Aboriginal and Torres Strait Islander peoples, including for diabetes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/39377/original/nw6stxnh-1390189117.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health minister Peter Dutton: ‘We are committed to reducing waste and spending on administration and bureaucracy’.</span>
<span class="attribution"><span class="source">AAP Image/Daniel Munoz</span></span>
</figcaption>
</figure>
<p>In between these extremes we have some <a href="http://blogs.crikey.com.au/croakey/2014/01/03/medicare-locals-under-review-what-croakey-contributors-and-others-want-to-see-and-what-they-fear/">mixed views in other submissions</a>. </p>
<p>On the positive side, there is some great work on health promotion and coordination which might deliver considerable health savings in the longer term if not cut off at the knees. There are also more voices at local level getting together to map what services exist, weigh up what is needed and plan to get the care the community prioritises. </p>
<p>But there is some duplication and wasted effort when MLs provide services now that are competing with other providers rather than filling gaps.</p>
<p>The name is also a problem, as people think they can make payment claims at the ML – a role for the national Medicare offices. </p>
<p>Overall, there is a strong case to let the MLs have a few more years to prove their worth and to see what savings elsewhere in the health system may be countable by the ML-driven effect on reducing hospital costs, unnecessary tests, screening and doctor visits and the burden of chronic conditions. The current UNSW-Monash-Ernst and Young <a href="http://www.cphce.unsw.edu.au/news-events/news/2013/10/medicare-local-how-are-they-doing">evaluation</a>, (separate to the review), should shine some light on these questions.</p>
<h2>What are the likely review outcomes?</h2>
<p>There are three broad categories of possible outcomes and we may not know before the federal budget in May. </p>
<p>The first is a “let it run longer and see what the evaluation says” approach, with minor tweaks to clarify roles and perhaps changing the name. </p>
<p>The second is more drastic: to cut the ML roles by, for example, taking much of the preventive health planning and education functions out. This would leave a focus on service delivery, while trying to reduce duplication of effort.</p>
<p>The third is to axe the MLs entirely and phase a return to something more like the old Divisions of General Practice.</p>
<p>The two more drastic approaches would weaken Australia’s primary health care system. It would go against the professional and community input to the national health reform discussions in 2008-09. And state governments might have very negative views about radical chopping and changing of this scale at this time.</p>
<h2>How do the economics stack up?</h2>
<p>MLs were set up with a modest budget. Depending how they are counted, the savings from axing them are likely to be less than A$1 billion over four years, allowing for transition arrangements and current contract commitments to be met. </p>
<p>There are certainly [bigger fish to fry](http://www.theage.com.au/comment/healthcare-gp-copayments-not-the-real-answer–there-are-far-better-ways-to-put-budget-back-in-shape-20140106-30dfu.html?utm_source=E-Healthcare+Brief+%28Current%29&utm_campaign=092e07dca9-AHHA_e_healthcare_brief_11+June_2013&utm_medium=email&utm_term=0_910dbd9c84-092e07dca9-245387337&ct=t(AHHA_e_healthcare_brief_21_March_20133_21_2013) in health savings. These include the Grattan Institute’s <a href="https://theconversation.com/fixing-australias-bad-drug-deal-could-save-1-3-billion-a-year-12707">proposed Pharmaceutical Benefits Scheme reform</a>, which might save A$1.3 billion a year, or removing the private health insurance rebate. Reducing the rebate by 25% <a href="https://theconversation.com/why-its-time-to-remove-private-health-insurance-rebates-16525">could save</a> A$549 million per year. </p>
<p>We need a rational analysis rather than an ideological knee-jerk reaction to another Labor hangover; we need to give Medicare Locals a chance to improve health outcomes and consider building on their strengths after more thorough evaluation. Professor Horvath has a tough gig ahead and will not be able to please all the stakeholders. </p>
<hr>
<p><strong>Further reading:</strong></p>
<p><a href="https://theconversation.com/gp-consultations-are-often-more-complicated-than-you-think-21953">GP consultations are often more complicated than you think</a></p>
<p><a href="https://theconversation.com/six-dollar-co-payment-to-see-a-doctor-a-gps-view-21915">Six dollar co-payment to see a doctor: a GP’s view</a></p>
<p><a href="https://theconversation.com/paying-doctors-to-keep-patients-healthy-if-the-price-is-right-21316">Paying doctors to keep patients healthy – if the price is right</a></p>
<p><a href="https://theconversation.com/mind-the-gap-6-gp-visit-proposal-ignores-the-evidence-21754">Mind the gap: $6 GP visit proposal ignores the evidence</a></p>
<p><a href="http://www.informa.com.au/conferences/health-care-conference/future-of-medicare-conference">The Future of Medicare Conference</a> opens on 13th August in Sydney.</p><img src="https://counter.theconversation.com/content/22008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Corbett has worked as a senior executive service member of the Department of Health and Ageing. </span></em></p>Primary health care in Australia is a messy beast, with many heads and all sorts of body parts. But it’s centrally important because it plays a major role in achieving public health outcomes, such as better…Joan Corbett, Adjunct Associate Professor, Public Health, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/178812013-09-09T20:40:27Z2013-09-09T20:40:27ZBland is best? Bipartisan health platform left no room for policy<figure><img src="https://images.theconversation.com/files/30991/original/dyz3yxtn-1378706958.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Peter Dutton and Tanya Plibersek at the National Press Club where, like the rest of the campaign, the parties seemed to vie to be blander.</span> <span class="attribution"><span class="source">Penny Bradfield/AAP</span></span></figcaption></figure><p>The dictionary has many words that could describe health policy in the 2013 federal election campaign – anodyne, soporific and vapid all come to mind. </p>
<p><a href="http://beta.afr.com/p/australia2-0/health_policies_avoid_the_vital_0iHhhvIB8QEoZDJIftBsZJ">Australia’s health policy problems</a> cannot afford the same vacuity from the next government so here’s hoping the campaign wasn’t a sign of things to come.</p>
<p>Health policy is traditionally a Labor strength and so it’s easy to understand why the Coalition was keen to avoid any attention to the area. Every day there was a discussion about health was a day the Coalition was on the back foot. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=468&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=468&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30968/original/nsc7cfgd-1378695133.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=468&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<h2>No counter for ‘small target’</h2>
<p>The Coalition’s “small target” strategy had few commitments, a net cost of only A$344 million over the next four years (the forward estimates’ period), and no apparent nasty surprises.</p>
<p>What’s puzzling is that the Labor Party didn’t advance visionary policies to garner public attention and focus the debate. </p>
<p>Sure, Kevin Rudd and Tanya Plibersek tried to raise fears about cuts to “frontline services”. Initially, shadow minister Peter Dutton had claimed that Medicare Locals (a Labor creation designed to provide a platform for primary-care services to support general practice, such as physiotherapy and other allied health services, and local planning) would be “reviewed”. </p>
<p>But Opposition leader Tony Abbott and Dutton subsequently <a href="http://www.politifact.com.au/truth-o-meter/statements/2013/aug/29/tony-abbott/what-coalitions-position-medicare-local/">backpedalled furiously</a> on comments that gave rise to concerns about their abolition.</p>
<p>Labor has experience with bold health policies. In the 1970s, the party fought bitter elections to introduce <a href="http://trove.nla.gov.au/work/23765893?q&versionId=43104213">Medibank</a>. </p>
<p>More recently, both Mark Latham’s 2004 [Medicare Gold](http://acoss.org.au/images/uploads/AJSI_Vol423.pdf](http://acoss.org.au/images/uploads/AJSI_Vol423.pdf) and then-opposition leader <a href="http://www.abc.net.au/news/2007-08-23/rudd-announces-hospital-takeover-plan/648122">Kevin Rudd’s 2007 promise</a> to “call a referendum for the Commonwealth to take over the running of hospitals if necessary” were received positively by voters.</p>
<h2>Why the reticence?</h2>
<p>A number of hypotheses – listed in the table below – might explain Labor’s policy gap.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30976/original/d5k3mvdb-1378700046.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Only insiders can know the reason or the combination of these reasons (and any others not listed) that accounted for the strategy Labor pursued.</p>
<p>In the dying hours of the campaign, Labor trumpeted its claim as the party of Medicare with a <a href="http://www.medicalobserver.com.au/news/labor-takes-final-dig-at-the-coalitions-health-policy--with-cake">30th birthday celebration/cake</a>. </p>
<p>Health policy now needs to build on Medicare’s strengths to address contemporary problems better, especially how we strengthen our primary-care system’s ability to manage chronic disease and multi-morbidity (having many illnesses at once). </p>
<p>This isn’t going to be easy. </p>
<h2>Tackling the big issues</h2>
<p>The incoming government’s <a href="http://lpaweb-static.s3.amazonaws.com/The%20Coalition%E2%80%99s%20Policy%20to%20Boost%20Dementia%20Research.pdf">policy to expand research into dementia</a>, hopefully including health and <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8706894">aged-care systems research</a>, is a good idea but could have gone further.</p>
<p>Labor could have built on its Medicare Locals platform to signal primary-care system reform. Given the <a href="http://aphcri.anu.edu.au/sites/aphcri.jagws03.anu.edu.au/files/research_project/252/full_report_18476.pdf">weak evidence base</a> of what works in system reform in primary care, Labor could have started a system redesign effort, perhaps funding trials of new approaches to primary health-care funding and delivery. </p>
<p>This wouldn’t have broken the bank and could have even been electorally appealing, offering Medicare Locals the potential to be in a trial. It could have been funded by addressing waste in the health-care system (such as <a href="http://grattan.edu.au/publications/reports/post/australias-bad-drug-deal/">paying too much for pharmaceuticals</a>). </p>
<p>The issue for the incoming government is that the need for primary-care reform won’t go away. Primary-care reform doesn’t have to involve Medicare Locals. They could be by-passed with policies based on changing financial incentives on general practitioners, such as <a href="https://theconversation.com/doctors-fee-for-service-doesnt-mean-price-is-right-1186">blending fee-for-service and capitation payment models</a> (these latter involve paying a medical practitioner a set amount for each patient over a period of time). </p>
<p>But Medicare Locals are the only “game in town” in terms of a primary-care platform. The incoming government will need to overcome its apparent ambivalence towards them to allow proper consideration of all policy options.</p>
<p>Voters have been rightly disappointed by the health “options” presented to them at this election. It’s unfortunate that what they regard as <a href="http://www.newspoll.com.au/opinion-polls-2/opinion-polls-2/">one of the most important</a> election issues was buried in a blancmange of bipartisan blandness during the election campaign.</p><img src="https://counter.theconversation.com/content/17881/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett has received funding from the NHMRC for aged care systems research. He is also on the Board of the Northern Melbourne Medicare Local. </span></em></p>The dictionary has many words that could describe health policy in the 2013 federal election campaign – anodyne, soporific and vapid all come to mind. Australia’s health policy problems cannot afford the…Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/176282013-08-29T20:20:08Z2013-08-29T20:20:08ZAbsence of health issues on election agenda bodes ill for much-needed reform<figure><img src="https://images.theconversation.com/files/30202/original/sk84dgsw-1377756529.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health care is one of the top three issues of concern for Australian voters, but it
has received little attention in this election campaign.</span> <span class="attribution"><span class="source">Esther Simpson</span></span></figcaption></figure><p>So far in this election campaign, the Coalition has provided dollar promises for worthy projects but no new health policy initiatives. The government has mentioned one policy of note – to remove family tax benefits from parents who don’t immunise their children.</p>
<p>How, then, can we possibly measure the major parties’ plans for solving the many problems that compromise the delivery of sustainable, quality health care in our country?</p>
<p>Health care in Australia is beset with structural inefficiencies, inappropriate models of care for the diseases we face, and cost increases that are producing major inequities in access. The latter is particularly obvious in rural communities. </p>
<p>Major barriers to real change remain opposition from those with vested interests in maintaining the status-quo and a lack of political leadership to take us on the necessarily long (ten years or more) reform journey that doesn’t fit with the short-term thinking that election cycles engender. </p>
<p>But if we do take that journey, it’s important to have a clear vision of what an appropriately reformed health-care system should look like.</p>
<h2>An imagined future</h2>
<p>Imagine the following. The year is 2023. The Commonwealth has become the single funder of the public health system. </p>
<p>An independent statutory authority has been established to fund a number of “regional health authorities” that are charged with delivering a model of care that emphasises prevention, timely treatment, and quality, cost-effective care based on need rather than financial status.</p>
<p>These regional authorities are funded on a per capita and local needs basis; state borders are no longer a barrier to efficient health care. The authorities contract a series of providers in their region to supply patient-focused integrated hospital, community and primary-care services. </p>
<p>Quality and safety data are collected and published.</p>
<p><strong>Primary care</strong></p>
<p>There’s a new model of primary care with a strong focus on disease prevention. People are encouraged to enrol in a primary health-care practice and work in partnership with health professionals to share responsibility for their well-being. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30205/original/wh2dmcj8-1377757154.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In a better health-care system, people would be encouraged to work in partnership with health professionals to share responsibility for their well-being.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The result is that we don’t just visit a medical practice when we’re ill, we attend to receive integrated primary care with a team of appropriate health professionals, who work collaboratively to help us stay well.</p>
<p>There are very good reasons for this approach. There’s no better use of health-care dollars than ensuring children get a healthy start to life; an obese four-year-old child is very likely to be an obese adult with attendant illnesses. </p>
<p>Continuity of care also provides us with the best chance to detect early signs of mental illness when serious problems can still be avoided.</p>
<p>Primary-care practices, which, significantly, are not doctor-centric, work under the umbrella of primary health-care organisations, which have evolved from poorly structured Medicare Locals.</p>
<p>These act as central service providers for linked, but clinically autonomous local practices and offer clinical services including acute services that don’t require hospital facilities, sparing local emergency departments from inappropriate attendances.</p>
<p>They also provide associated practices with business skills, bulk purchasing, continuing education, the collection of outcome data (now a mandatory requirement), and IT services (including help with further development of now-popular patient-controlled electronic health records). </p>
<p>Primary, community, and hospital care are all seamlessly integrated.</p>
<p><strong>Medical workforce</strong></p>
<p>Nurses and allied health professionals deliver much of the prevention program. Most doctors dissatisfied with the “turnstile-medicine” approach fostered by (the current) fee-for-service payments have accepted the opportunity for payment by contract with a regional health authority.</p>
<p>GPs are financially much better rewarded in this system, and the attractiveness of working in the team environment is attracting more medical graduates to primary care (unlike in 2013, when very few medical graduates were interested in such careers).</p>
<p>There’s been a major revision of clinical training in the nation’s universities. “Inter-professional learning”, which has students of medicine, nursing, dentistry as well as allied health professions, spending time learning together, has produced a mutual appreciation of the specific skills of each group. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30208/original/rkq4xqyv-1377757442.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Combining skills for a team-medicine approach would be more satisfying for professionals and patients alike.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Combining skills has also resulted in a “team-medicine” approach, which is much more satisfying for professionals and patients alike. How different this is from the professional “silo” mentality of a decade ago when everyone worked separately. </p>
<p>Medical schools in rural-based universities with programs for students with a strong rural affiliation and a desire for a country-based career, are seeing significant numbers of graduates living and working outside of city centres. </p>
<p>Medical education has been shortened without any damage to required learning and is much less focused on hospital-based rotations, with more student time spent in community settings. The old mandatory internship program has been abandoned in favour of post-graduate entry into vocational training programs.</p>
<p><strong>Hospitals</strong></p>
<p>State governments no longer receive Commonwealth funds to run their hospitals but they continue to own and operate them. Funding comes through contracts with regional health authorities. </p>
<p>The services offered by a hospital is negotiated, with emphasis on the quality rather than the number of services on offer. </p>
<p>Role delineation among all the hospitals within a given region avoids duplication and a return to the old system where individual hospitals tended to be islands in an ocean of health-care without coherence. </p>
<p>Many private hospitals offer their services to regional health authorities.</p>
<h2>A first step?</h2>
<p>So, let’s return to the present, August 2013. Given health care is one of the top three issues of concern for Australian voters, it’s disappointing that health-system reform has so far received so little attention in this election campaign. </p>
<p>We should reasonably expect our politicians to be seriously challenged to provide a detailed and clear vision of the reforms they would pursue to create a more equitable and cost-effective health system that will met our future needs.</p>
<p>But we will almost certainly not get this. And perhaps that says as much about the demise of decent journalism in this country as it does about the state of our democracy and politicians.</p><img src="https://counter.theconversation.com/content/17628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Dwyer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>So far in this election campaign, the Coalition has provided dollar promises for worthy projects but no new health policy initiatives. The government has mentioned one policy of note – to remove family…John Dwyer, Founder of the Australian Health Care Reform Alliance & Emeritus Professor, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/129652013-04-08T20:33:28Z2013-04-08T20:33:28ZGive Medicare Locals a chance to improve health equity<figure><img src="https://images.theconversation.com/files/21562/original/b5q4hrfp-1363846011.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicare locals aim to reduce visits to emergency departments by coordinating after-hours care.</span> <span class="attribution"><span class="source">image from shutterstock.com</span></span></figcaption></figure><p>While independent, government-funded <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/medilocals-lp-1#.UUu8Lo7F--I">Medicare Locals</a> are still in their embryonic form, opposition health spokesperson Peter Dutton <a href="http://www.theaustralian.com.au/national-affairs/coalition-will-abolish-all-medicare-locals/story-fnhi8fqc-1226596742854">has hinted</a> that, if elected, a Coalition government would scrap the bureaucracies and redirect funds to front-line patient care. </p>
<p>“We support a role for the coordination of primary care, but we don’t support money being prioritised away from patients into vast bureaucratic structures,” <a href="http://www.peterdutton.com.au/MediaHub/MediaReleases/tabid/75/articleType/ArticleView/articleId/349/Desperate-Plibersek-misrepresents-report-to-back-bureaucracy-over-patients.aspx">Dutton said</a> last month, though the Coalition has <a href="http://www.medicalobserver.com.au/news/medicare-locals-to-stay-libs-send-mixed-message?utm_medium=email&utm_campaign=Daily+Enews+-+05042013+-+to+use&utm_content=Daily+Enews+-+05042013+-+to+use+CID_b14f00d38d7c4989dab5fff431729592&utm_source=Email%20marketing%20software&utm_term=Medicare%20Locals%20to%20stay%20Libs%20send%20mixed%20message">not clarified its position</a> on Medicare Locals.</p>
<p>Medicare Locals coordinate (but only provide a limited range of) health services. They’re <a href="http://www.yourhealth.gov.au/internet/yourHealth/publishing.nsf/Content/MedicareLocalsDiscussionPaper/$FILE/Discussion%20Paper.pdf">designed</a> to identify local needs, streamline patients’ journeys through services, support health workers, facilitate initiatives and be accountable to the community. </p>
<p>There are already encouraging signs that Medicare Locals are starting to deliver results. But if they’re axed, Australia could be derailing its path to a more equitable health system.</p>
<h2>Early signs of progress</h2>
<p>For the first time, primary health-care providers across Australia have come together to plan after-hours services to meet the needs of their local communities. In the Hunter, New South Wales, for example, a <a href="http://www.huml.com.au/site.php?site=1">telephone triage system</a> helps patients access services they need, including transport. This takes the load off hospital emergency departments, which treat patients if they’re unable to access a general practitioner after hours. </p>
<p>Many other Medicare Locals have <a href="http://www.wentwest.com.au/afterhours/">established websites</a> where patients can find an after-hours GP in their local area. These services are linked to the national <a href="http://www.yourhealth.gov.au/gphelpline">after-hours GP help line</a> which is particularly useful in providing advice for parents when their young children get coughs or fevers. </p>
<p>Other Medicare Locals are working on increasing access to doctors and allied heath-care providers in nursing homes, again preventing unnecessary trips to emergency departments. </p>
<h2>Addressing inequality</h2>
<p>Certain groups of Australians suffer disproportionately from health problems. <a href="https://theconversation.com/diabetes-among-indigenous-australians-at-crisis-point-10644">Indigenous Australians</a>, people from lower socioeconomic backgrounds and those living in rural and remote areas are at higher risk of chronic diseases such as diabetes and heart disease.</p>
<p>The <a href="http://www.healthstats.nsw.gov.au/Indicator/bod_lexbth_lhn">life expectancy</a> gap between the most and least disadvantaged parts of NSW, for example, is 4.6 years. And <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter218Oct+2010">Indigenous Australians’</a> life expectancy is 9.7 and 11.5 years less for women and men respectively.</p>
<p>This is partly because disadvantaged groups have higher rates of risk factors such as obesity and smoking but also <a href="http://www.google.com.au/url?sa=t&rct=j&q=turrell%20g%2C%20stanley%20l%2C%20de%20looper%20m%2C%20oldenburg%20b.%20health%20inequalities%20in%20australia%3A%20morbidity%2C%20health%20behaviours%2C%20risk%20factors%20and%20health%20service%20use.%20.%20canberra%3A%20australian%20institute%20of%20health%20and%20welfare%2C%202006%20%20contract%20no.%3A%20phe%2072.&source=web&cd=1&ved=0CDUQFjAA&url=http%3A%2F%2Fwww.aihw.gov.au%2FWorkArea%2FDownloadAsset.aspx%3Fid%3D6442459734&ei=OFtKUac16bOJB725gdgP&usg=AFQjCNFPHmT1PPPA70yiWtiAq7KEveqUCQ&bvm=bv.44158598,d.aGc">unequal access</a> to preventive and other health services.</p>
<p>In some areas, many people were born overseas, have poor English language skills, limited education or poor health literacy (the knowledge and skills to stay healthy). This complicates preventive care and early treatment.</p>
<p>In an attempt to address this problem, Sydney’s <a href="http://www.anpha.gov.au/internet/anpha/publishing.nsf/Content/MedicareLocalsGrants">Inner West Medicare Local</a> has been funded by the National Preventive Health Agency to work with GPs, local government and community organisations to engage people with poor health literacy in preventive care.</p>
<h2>A quality primary care system</h2>
<p>Australia has a comparatively strong but fragmented primary health care system. An older person needing extra help at home, for example, often has to be assessed by a number of service providers separately and often information is not shared. This frustrates patients and their families as they receive uncoordinated or inappropriate services. Fragmented care is particularly detrimental for older people and those with complex long-term problems such as diabetes and depression.</p>
<p><a href="http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/Publications_PDFs/E46.pdf">International research</a> has demonstrated that primary health care is a key part of the solution to these inequities. This is because disadvantaged and vulnerable groups are more likely to have multiple risk factors and health problems – and primary health represents a comprehensive means of diagnosis and management. It is also generally more accessible and affordable for people with limited resources than more specialised care.</p>
<p>Good care requires strong links between hospitals and community-based services, multidisciplinary team care and proactive approaches to prevention, something many hope the Medicare Locals will achieve.</p>
<p>A major opportunity comes with the Health Communities plans Medicare Locals are currently developing for their local areas. These will identify which population groups are using services and then develop more flexible locally responsive services. So far, some Medicare Locals have found children in disadvantaged suburbs have lower rates of immunisation and thus they can work with the other local health services to <a href="http://www.actml.com.au/newsroom/media-releases/act-medicare-local-listening-and-acting-to-improve-our-health">improve access and promote uptake</a> in these areas.</p>
<h2>Where to next?</h2>
<p>The Commonwealth government has <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/nhra-briefings-qon-brisbane#.UUuu-Y7F--I">invested approximately A$171 million a year</a> to fund the 61 Medicare Locals across Australia. This is a relatively small amount of money in the A$53 billion-plus health and ageing budget.</p>
<p>The health care reform reports <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/nhhrc-report-toc">recognise</a> the pivotal position of primary health care in preventing more acute illness and saving money down the track, with Medicare Locals playing an important role in prevention and early detection.</p>
<p>Although there is goodwill for Commonwealth- and state-funded services to work together at the local level, more integrated care involves making health professional roles and services more flexible. These changes are difficult to achieve across different professions, organisations and with limited resources.</p>
<p>The success of Medical Locals at reducing health inequities will depend on their ability to relate to local communities. If Medicare Locals can work with local government and those representing vulnerable and disadvantaged groups – and listen to what they have to say – they may be able to tackle problems that more established services have not.</p>
<p>These long-term relationships will need commitment and trust. They also require time – something that Medicare Locals may not have.</p><img src="https://counter.theconversation.com/content/12965/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Harris a board member of the Inner Western Sydney Medicare Local. </span></em></p><p class="fine-print"><em><span>Nick Zwar is a board member of the South East Sydney Medicare Local. </span></em></p><p class="fine-print"><em><span>Elizabeth Harris does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While independent, government-funded Medicare Locals are still in their embryonic form, opposition health spokesperson Peter Dutton has hinted that, if elected, a Coalition government would scrap the bureaucracies…Mark Harris, Director, Centre for Primary Health Care and Equity and Centre of Research Excellence in Obesity Management and Prevention in Primary Health Care, UNSW SydneyElizabeth Harris, Senior Research Fellow, UNSW SydneyNicholas Zwar, Professor of General Practice and Head of Undergraduate Education, School of Public Health and Community Medicine, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/118712013-02-13T03:31:44Z2013-02-13T03:31:44ZElection places national health reform at a crossroads<figure><img src="https://images.theconversation.com/files/20204/original/5bxpqghw-1360722158.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Until the Opposition releases its health policy, it's impossible to know what will happen to the health reform agenda.</span> <span class="attribution"><span class="source">Alejandro Polanco</span></span></figcaption></figure><p>Prime Minister Julia Gillard has announced the federal election will be held in mid-September. So, what will happen to the ambitious program of health reform that the Labor government is in the process of implementing? </p>
<p>Medicare is popular with the community, but that hasn’t stopped health being <a href="http://books.google.com.au/books/about/The_Public_private_Mix_for_Health.html?id=ETdDjWLKDyMC&redir_esc=y">an election issue</a> in most, if not all, of the federal elections held over the last three decades. For most of that time, the major difference between the major parties has been the role of public finance vs private insurance. </p>
<p>But come the 2007 election, the focus shifted fairly and squarely to the well-being of public hospitals. This was somewhat puzzling because the responsibility and ownership of public hospitals rested with the states and territories. But they have relied on Commonwealth funding to support public hospitals since the mid-20th century, and increasingly so under Medicare with its universal access to free public hospital treatment. </p>
<p>As hospital costs outstripped the growth in state and territory revenue, governments blamed the Commonwealth for reneging on its share. Labor under Rudd promised to “end the blame game” between the states and the Commonwealth and embark on a new era of reform and co-operation.</p>
<h2>The age of health reform</h2>
<p>Fast forward to 2013 and Labor’s health reform program is well underway, with the 2011 <a href="http://www.federalfinancialrelations.gov.au/content/npa/health_reform/national-agreement.pdf">National Health Reform Agreement</a> providing its basis and framework. The broad vision is for a national system, with more local decision-making, accountability and public reporting; incentives for more efficient use of resources; and emphasis on out-of-hospital care and prevention. </p>
<p>Public hospitals have been reorganised into <a href="http://www.health.gov.au/internet/yourhealth/publishing.nsf/content/lochospnetwork#.URNFcVrtgzE">Local Hospital Networks</a> (the names and the extent of reorganisation vary by state) with a high degree of local autonomy and accountability. But states and territories are still the public hospital and community services system managers. </p>
<p>The Commonwealth has committed to pay an agreed share of the growth in public funding to the states and territories. This share will be based on a price set according to the type of patient or treatment, and is intended to improve hospital efficiency. A new agency, the <a href="http://www.ihpa.gov.au/internet/ihpa/publishing.nsf">Independent Hospital Pricing Authority</a> has been established and has already provided its first pricing determination for 2012-13. The determination for 2013-14 is to be released this month. Its work is well under way.</p>
<p>The complementary part of “a national system with local control” are <a href="http://medicarelocal.com.au/">Medicare Locals</a>, 61 of which have been established across the country. Their role is to support all primary-care providers, liaise with hospitals, and identify and fill gaps in local services.</p>
<p>A second agency, the <a href="http://www.nhpa.gov.au/interned/nhpa/publishing.nsf">National Health Performance Authority</a> has also been established. It has taken over the <a href="http://www.myhospitals.gov.au/">myhospital website</a>, and released <a href="http://www.nhpa.gov.au/internet/nhpa/publishing.nsf">its first report</a> on emergency waiting times in 2012. Its second report on primary-care providers is due soon.</p>
<p>Yet another such body is the <a href="http://anpha.gov.au/internet/anpha/publishing.nsf">Australian National Preventive Health Agency</a>, which will manage national campaigns, and fund research and fellowships.</p>
<h2>More to be done</h2>
<p>So far, the focus of implementation has been public hospitals, their governance and funding. Presumably Labor will continue developing these reforms. Their initial reform plan is quite clear that the steps outlined above were not intended to be the end but rather the start of the process. And there are a number of issues that still need to be addressed. </p>
<p>Private hospitals, which are increasing in size and complexity of case-mix, have to be brought into the system. Although Medicare Locals have the potential to play a pivotal role, their ability to exert influence may be limited, as the arrangements for primary care and community services are still fragmented and responsibilities diffused throughout the system. </p>
<p>Funding streams have been kept separate and distinct across hospitals, medical services and pharmaceuticals, and there’s no flexibility to move money across programs or pool funds. And there’s been no attention how new technologies, often considered the major driver of increasing health-care costs, are used throughout the public and private systems. </p>
<p>The incentives for individual providers (in hospitals and in other services) remain unchanged, in contrast to reform efforts in other countries, which have a stronger focus on changing payment mechanisms.</p>
<h2>The devil you know</h2>
<p>Until the opposition releases its health policy, there’s limited information to gauge how they will approach the current state of the health system. And whether they will continue down the path already started or radically change direction. </p>
<p>Tony Abbott has been critical of the number of new agencies – and therefore new bureaucracies – created. What might we see dismantled? And would that affect the development of more transparency and accountability, trends that are well underway in other mature health systems? There’s a promise of more public say in the running of hospitals and schools – but will that mean further changes to governance? </p>
<p>Presumably, we can expect continued support for the private sector and the private insurance industry. But will it go as far as allowing an opt-out of Medicare in the form suggested by the reform commission, which was rejected by the Gillard government?</p>
<p>Perhaps the most encouraging promise so far is the Coalition’s pledge to <a href="https://theconversation.com/coalition-commitment-to-medical-research-funding-is-welcome-11880">support medical research funding</a> and the implementation of recommendations from the <a href="https://theconversation.com/mckeon-review-we-need-to-integrate-research-and-health-services-9742">McKeon review</a>. Let’s hope that in this election, both parties support medical and health services research as the basis for continuing the development of our health system.</p><img src="https://counter.theconversation.com/content/11871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Hall receives funding from the Australian Research Council, the National Health and Medical Research Council, and the Australian Primary Health Care Research Institute. She is a member of the Independent Hospital Pricing Authority. The views expressed here do not represent the views of any of these organisations.</span></em></p>Prime Minister Julia Gillard has announced the federal election will be held in mid-September. So, what will happen to the ambitious program of health reform that the Labor government is in the process…Jane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/66782012-05-28T20:38:48Z2012-05-28T20:38:48ZHave Medicare Locals been set up to fail?<figure><img src="https://images.theconversation.com/files/10797/original/4zrxm369-1337308831.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicare Locals have a big task, with a modest budget.</span> <span class="attribution"><span class="source">AAP/Dave Hunt</span></span></figcaption></figure><p>Opposition Health spokesman Peter Dutton has called Medicare Locals “an extra layer of bureaucracy”, and signalled the Coalition will remove them if it’s elected. His conclusion that they’re a waste of time does not have a basis in evidence because the final 25 of the 62 Medicare Locals will not come into being until July 1.</p>
<p>Primary health care in Australia is a messy beast, with many heads and all sorts of body parts. But it’s centrally important because it plays a major role in achieving public health outcomes. </p>
<p>Primary health care is about more than medical care – it includes health promotion, illness prevention, care of the sick, patient advocacy and community development. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16202000">Countries with a strong emphasis on it</a> have lower health-care costs, greater health equity and better population health outcomes. </p>
<p>A <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/report-primaryhealth">Primary Health Care Strategy</a> was developed by the Department of Health and Ageing in 2010 as part of the broader health-system reforms initiated in 2007. Its focus includes improving access and reducing inequality; better management of chronic conditions; and more attention to prevention. </p>
<p>A key component of the government’s reform is the establishment of Medicare Locals.</p>
<h2>What are Medicare Locals?</h2>
<p>Medicare Locals are primary health-care organisations established to coordinate care delivery and tackle local needs and service gaps. Their task is to drive improvements in health and ensure that services are better tailored to meet the needs of the communities they serve. </p>
<p>More specifically, Medicare Locals’ task is to deliver:</p>
<ul>
<li>better planning for all primary health-care services, based on patient needs and improved equity;<br></li>
<li>integration of new GP super clinics with other services;<br></li>
<li>transparency in the planning process, and about health outcomes;<br></li>
<li>consultation with the community on filling gaps and needs;<br></li>
<li>and more individual care plans with communication to make them work.</li>
</ul>
<p>This is a big ask, especially with modest budgets to run the Medicare Locals (a total of $417 million for all 62 of them). And since the big source of funds for primary care services is separate and allocated automatically by claims from the Medicare Benefits Scheme.</p>
<p>The first Medicare Locals have now been in operation for a number of months and there will be 62 operating by July 2012.</p>
<h2>Hurdles and challenges</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10802/original/jxg88qky-1337316591.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medicare Locals will be providing primary care for local communities.</span>
<span class="attribution"><span class="source">flickr/Slightly Everything</span></span>
</figcaption>
</figure>
<p>Medicare Locals will find it hard to take a broad view of primary health care. They will have to think about social as well as medical care, and community as well as individual problems. They will face particular challenges in socioeconomically disadvantaged communities. </p>
<p>These organisations will need to develop a population and health-service plan to address needs in their local area. So they will need to look at their population and develop primary prevention programs for it. </p>
<p>They will need to support integrated care and enhance coordination for people with chronic diseases and complex needs. The latter of these tasks will be difficult but we think the development of primary prevention programs will be the most challenging.</p>
<p>Medicare Locals work mainly with general practices, which are usually private businesses, working on a fee-for-services model. This model is characterised by time-limited episodic care and one that representative bodies of medical practitioners will fight hard to protect. </p>
<p>But it’s not a model that’s really conducive to inter-sectoral collaboration (across the areas of housing, social services, education and so on), which is the main characteristic of primary health care. Neither is it really conducive to primary prevention. </p>
<p>We know the drivers of disadvantage, and of ill health linked to that disadvantage, are outside the health system. And while macro-level policy may talk about primary health care, policy at the Medicare Local level will have enormous challenges in re-orienting thinking about how to deliver care. And how to focus on prevention rather than treatment.</p>
<h2>Sharing responsibility for health</h2>
<p>The performance of Medicare Locals warrants careful scrutiny. If they do well, we will see collaboration with a range of vital health-service providers beyond general practitioners, and this will certainly include Aboriginal Medical Services and aged care providers. </p>
<p>If good practice is applied, communities will hear from their Medicare Local and will be able to find out about existing gaps and plans that are being put in place to fill these. </p>
<p>Preventative health efforts will be well coordinated and led. Patients will see improvements in the timeliness and quality of local care and may be pleasantly surprised to find that their health records move around with them – even from hospital to community and back again! </p>
<p>It’s a big ask, but no more than we should expect because health is a shared responsibility. Hopefully, the Coalition will give Medicare Locals a chance rather than blindly stamping them out before their bloom.</p><img src="https://counter.theconversation.com/content/6678/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opposition Health spokesman Peter Dutton has called Medicare Locals “an extra layer of bureaucracy”, and signalled the Coalition will remove them if it’s elected. His conclusion that they’re a waste of…Joan Corbett, Associate Professor, Public Health, University of CanberraRhian Parker, Associate Professor and Senior Research Fellow, Centre for Research and Action in Public Health, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/8512011-11-06T19:40:53Z2011-11-06T19:40:53ZEverything you need to know about your Medicare Local (but didn’t know who to ask)<figure><img src="https://images.theconversation.com/files/2846/original/ML.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicare Locals are the primary health care flagship of the national health reforms being rolled out by the Labour Government.</span> <span class="attribution"><span class="source">AAP</span></span></figcaption></figure><p>Health Minister Nicola Roxon announced 38 new Medicare Locals last week, bringing the total eventual number of organisations to 62. But so few of us know what they are or what they will do. </p>
<p>For starters, you should know that you can’t get a beer at a Medicare Local. But don’t let this deter you from reading on – your future health may depend on these new health organisations.</p>
<p>Medicare Locals are a new regional primary health care structure. Most people turn off at this point, which is a pity because if they work well, these new organisations will help improve our primary health care and make it more relevant for an ageing population. </p>
<h2>What are they and what do they do?</h2>
<p>Medicare Locals are the primary health care flagship of the national health reforms. They are regional organisations whose job is to plan and coordinate improvements in primary health care for a designated population. </p>
<p>They are intended to support front line primary health-care services and providers – especially general practitioners and private allied health providers – to improve their services, fill gaps, coordinate care and make it easier for patients to negotiate the maze of services.</p>
<p>They’ll be funded to tackle particular problems – after hours primary medical care, primary mental health care – and build links with hospitals and with other community based services like Aboriginal health, local councils, self-help groups and other social care organisations, to improve community health. </p>
<p>They’ll replace the Divisions of General Practice and extend their focus from general practice to private allied health and non-government organisations, which have previously been left out in the cold. In some states they may also take on some community health services. </p>
<h2>What can they do for the community?</h2>
<p>Mrs Jones has diabetes and high blood pressure which she manages as well as she can, but it’s sometimes difficult to maintain the healthier lifestyle that she needs. </p>
<p>She can get Medicare funding to see a dietician and exercise physiologist, but there’s a shortage of services in her area and the co-payment is too high. </p>
<p>Her general practitioner doesn’t refer people with diabetes to the local health service diabetes clinic as he is afraid of losing patients.</p>
<p>The Medicare Local might help her GP link better with allied health providers, and try to attract more dieticians to work in the area. </p>
<p>It might help the GP employ a part-time diabetes educator in the practice, and negotiate better referral arrangements with the diabetes clinic. </p>
<p>This nuts and bolts service improvement can help people like Mrs Jones get the services they need to maintain stay healthy. </p>
<p>It is painstaking, unglamorous work and Medicare Locals will have few sticks and carrots to encourage providers to play along. </p>
<p>Much of their success will depend upon goodwill and a commitment to patient care.</p>
<p>Meanwhile, Mr Smith has heart disease and chronic obstructive pulmonary disease, which lands him in hospital from time to time. The hospital has an education program but he finds it difficult to get there. </p>
<p>And, his GP isn’t always informed when he has been hospitalised, or when his treatment has been changed. </p>
<p>His doctor knows that Mr Smith is lonely and needs social support, but doesn’t know how to access it.</p>
<p>A Medicare Local can help hospitals improve communication with GPs so that Mr Smith gets properly coordinated follow-up care. </p>
<p>It may provide an education program in the community and its links with social care services may help his GP refer him to social support programs.</p>
<p>Meanwhile, the kids from the local housing estate are getting into trouble. There is nothing much to do, and some of the older ones have left school without a job. </p>
<p>It’s not hard to see more serious health and social problems down the track. </p>
<p>A good Medicare Local will see this as a health as well as social problem and might work with councils, youth organisations, churches and schools to set up recreational programs and help some back into education. </p>
<p>So much for the vision. But will Mrs Jones, Mr Smith and the local kids get the help they need? This remains to be seen but we know that all will not be plain sailing.</p>
<h2>Lurking dangers</h2>
<p>Medicare Locals are part of a vision for a more integrated health-care system. Their strength will lie in their ability to bring together a wide group of health service providers to address the community’s health problems. </p>
<p>But their weaknesses are threefold:</p>
<ul>
<li><p>Medicare Locals are not truly comprehensive. They won’t include community health (in some states) or hospitals, as did the Primary Care Trusts in England. So the system will remain fragmented. And although being separate may protect their budgets being raided by hospitals, they won’t be in a position to address the chronic imbalance between hospital and community care. </p></li>
<li><p>They will have limited resources and little authority to pull services into networks and fill service gaps. Health-care providers are notoriously prickly about their autonomy, and don’t take kindly to being told what to do. We could end up with plenty of action at the organisational level but less benefit for patients and communities.</p></li>
<li><p>Medicare Locals may find it hard to take a broad view of primary health care. They will need to think about social as well as medical care, and community as well as individual problems – all without alienating general practitioners who are a core part of primary health care. The Commonwealth, which is funding the whole enterprise, has little experience with broader primary health care. </p></li>
</ul>
<p>Medicare Locals will provide opportunities for bold new action where the vision is there and the partnerships are right. They won’t be able to deal with the really entrenched problems of our health system. </p>
<p>If experience in New Zealand and the United Kingdom are any guide, this is likely to be the first step on a longer march to stronger and more comprehensive primary health care.</p><img src="https://counter.theconversation.com/content/851/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gawaine Powell Davies does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health Minister Nicola Roxon announced 38 new Medicare Locals last week, bringing the total eventual number of organisations to 62. But so few of us know what they are or what they will do. For starters…Gawaine Powell Davies, Associate Professor, CEO and Director, Centre for Primary Health Care and Equity, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.