Who is doing what in primary health care reform? And what can we learn from the most promising Medicare Locals?
With so much expectation being placed upon primary health care reform and Medicare Locals, what can we learn from those of the new organisations that are expected to be pack-leaders?
That was the question I was asking when researching this piece just published by the online publication Inside Story (which also recently appeared as part of the regular IS supplement in the Canberra Times).
(If you’d like a copy of the print publication, it can be ordered here for $3 and is also available at selected bookshops including Readings in Melbourne, Gleebooks in Sydney, Avid Reader in Brisbane and Fullers in Hobart.)
As often happens, I ended up with more interviews and material than could be woven into the narrative of the piece.
Below are some of the case studies – from WA, Melbourne and western Sydney – that didn’t make it into the story but may be of interest to those with a healthy appetite for primary health care reform reading.
On related themes, the next Croakey post, by the University of Queensland’s Professor Philip Davies, will examine the history of the terms “primary care” and “primary health care”.
Aged care is the big issue
South West WA Medicare Local
Suzanne Leavesley, is the transitional CEO of the South West WA Medicare Local. Originally a speech pathologist, she previously worked in rehabilitation medicine, and divisions of general practice.
The Medicare Local covers 73 local government organisations, and plans to establish a health hub in each of the shires – places, for example in cafes, where community members can put forward their suggestions and feedback about community health issues and services. Five hubs have been established so far.
The organisation has a population health expert among its 16 staff, and the hubs will also be used to help inform local communities about their particular health issues.
“When we talked to reps from the Shire of Kojonup we told them what the health issues were according to the statistics, and asked what were their priorities. They told us they were aged care, aged care, aged care,” says Leavesley.
The organisation is also identifying gaps in services but has no plan to become a service provider. Leavesley says that the town of Darkan, for example, with a population of only 900 is having a baby boom. However, the town has no resident doctor.
“The idea of Medicare Locals is to bring all the bits of a jig saw together,” says Leavesley.
Let’s trial new funding models for high needs groups
The South Eastern Melbourne Medicare Local
Anne Peek is CEO of the South Eastern Melbourne Medicare Local. She has a background in health information and hospital management, and has worked with divisions of general practice since 1994.
She was previously CEO of the Dandenong Casey General Practice Association, which is one of the founding members of the South Eastern Melbourne Medicare Local but will continue as an independent organisation renamed the South Eastern Health Providers. Most of the division’s staff and programs will transfer across to the Medicare Local, which has organisational members.
The division has a history of successful collaboration, including establishing a research unit in partnership with Southern Health and Monash University, which aims to foster research useful and relevant to primary care. The Medicare Local will become one of the partners.
Below is an edited transcript of an interview with Anne Peek:
“Our catchment includes the City of Greater Dandenong which is said to be one of the most disadvantaged urban areas in Melbourne, with many of the indicators of disadvantage, including increased rates of unemployment. It also many cultural groups, and relatively high rates of drug and alcohol and mental health problems, and many refugees suffering the aftermath of trauma. One per cent of all the world’s refugees come to Dandenong.
I agree with the observation that you have more chance of being innovative in areas of disadvantage. While many GPs would prefer to work elsewhere, the ones that come to work here are amazing.
We have a lot of engagement and a very strong relationship with Southern Health, although its main hospital (Monash) is not in our catchment. We have a lot of representation at various levels and they are also on our strategic advisory committee, the main committee advising the board which will be made up of 12 member orgs. They were a partner in putting together the submission for the Medicare Local.
What we are probably proudest of and which we think will be a bit of a flagship for the Medicare Local is a diabetes coordination and assessment service that is in partnership with Southern Health, established in 2002. GPs refer their patients to the service, which does an initial assessment to see what services they need, what will suit them best for where they live, whether they have transport etc. this service will be run out of the ML. The service feeds back to the GP and monitors the patient. We have 500 GPs making about 1200 referrals a year to the service.
We plan to expand this approach beyond diabetes into mental health, and the care of Aboriginal and Torres Strait Islander patients.
A lot of what we’re doing is trying to knit all the different parts of the system together, or putting all the pieces of the jig saw together.
Aged care is another area where Medicare Locals could make some inroads. We’ve got to bring the public and private sectors together. The assessment service is a good tool for bringing a range of providers together. You can do a service agreement with them that builds them into a level of accountability.
One of the challenges is going to be addressing the expectations that Medicare Locals will be funding sources. Our budgets are still not huge. Time is going to tell as to the influence of Medicare Locals. There is a sense that the power will shift to primary care. We’ve just got to get the attention away from waiting lists and emergency department waiting times, which is what the public see. There is no interest really in the media or even politically to have wins in primary care. The politicians want to see waiting lists come down and people being able to get care in emergency departments.
Our population health assessment has shown very high needs among refugees. People who have suffered torture and trauma, and come from detention centres, their mental health issues are not being picked up early enough. We are looking to work with community leaders to give them the knowledge to help guide people to earlier help.
In five years time how should we be judged? You should look at data to show if things like the complications of chronic diseases have improved. Consumers should feel their GP is managing their care well and they are getting the services they need. I would hope the vulnerable communities, the refugees, are finding that their health and mental health issues are being dealt with in a much more significant and timely way. Health providers would want to feel the system is getting easier to manage. Consumers may not even realise the Medicare Local has made their lives easier. The Government will be looking for less burden on the hospitals. Another good measure will be that we’ve got a sustainable workforce, with GPs working in a multidisciplinary approach and their morale significantly improved.
We would like to trial capitation funding for refugee care – if we could move away from the fee for service model and pool all the funding sources, we could be so much more efficient and it would be easier to provide true multidisciplinary care. I think we should explore some different funding models, particularly in areas with disadvantaged groups.”
A new spirit of cooperation
Inner North West Melbourne Medicare Local
Chris Carter returned to Melbourne after 15 years in Perth, where he mainly worked with divisions of general practice, to take up a position as the Chief Executive Officer of the Inner North West Melbourne Medicare Local.
There were three divisions of general practice in the new Medicare Local’s catchment area, and its membership is open to any organisations delivering primary care within its catchment after June this year.
Carter says he has been impressed by the level of goodwill in Victoria towards Medicare Locals. “In the first couple of weeks I had the acting CEO of Melbourne Health come and seek me out, which was fantastic,” he says.
“There is quite a willingness to change, people are really quite keen to do things differently. I think that’s because of a whole range of historical issues – for example the Victorian system has far more experience of activity based funding, with that history they’re a lot clearer about primary care interfaces. The jurisdictions that haven’t had activity based funding will struggle because they will get a bit bogged down in the newness of it.”
Carter says his interactions with State Governments, the Commonwealth and community agencies about addressing afterhours care have been encouraging, displaying a new willingness to share data.
“Because we’ve come in with a new brief, the discussions have been refreshing,” he says. “Both the Commonwealth and the states want to do something in the after hours space but haven’t had a way to talk before. But we can come in as the middle people looking at the shared goal. It’s the most that I’ve seen that interjurisdictional cooperation for a long, long time in the health system.
“I was in a state health meeting the other day, talking about the ‘authorising environment’. Medicare Locals have become part of the ‘authorising environment’ – the Commonwealth is authorising Medicare Locals to take an active role in the conversation.
“Clearly there is a bit of pushback against that from some, but it’s been refreshing to sit down and have conversations with state health and the Commonwealth that haven’t been had before. That shift is quite important and that’s where it’s different.”
So far, their discussions have shown the fragmentation in afterhours care. “In inner Melbourne, nobody knows where after hours services are, when they’re open etc, which is quite astonishing for the second largest city in Australia.”
The Medicare Local will first focus on afterhours GP care, and then allied health, pharmacy, specialists, mental health, and oral health.
The major risks for the new organisation include, he says, managing expectations, “not achieving what we’ve been set out to do”, and the compressed timelines.
Carter says: “It’s a bit easier for the old Divisions of General Practice that had similar or the same catchments as the new Medicare Locals, they could ‘flick the switch’ between a Friday and a Monday, and start their new roles. For organisations like us that are bringing together multiple organisations, our journey is longer and harder. Doing that in a short time is a challenge.”
In five years time, the organisation should be judged by the experience of “Mr or Mrs Citizen with low income and diabetes” finding it easier to navigate the system, to access services in a timely and reasonable manner to broker services, to not replicate information and diagnostics, to access pathways of care.
For Dr Ines Rio, a GP who chairs the organisation’s board and who has worked in general practice and hospital settings, success will mean “that when the GPs tells that person they need to see a podiatrist or dietician or diabetes educator, they can access those services and the care is coordinated back with the GP. Then when the person needs renal dialysis, the GP can get advice from a tertiary centre, and the information flows between those sectors.”
Rio says Medicare Locals represent more than an evolutionary step for general practice and are “a very significant change”. She says: “The divisions came about 20 years ago to connect isolated GPs to one another, but this is about connecting general practice to the rest of the health care system and bringing primary health care together and then increasing the capability and capacity of that primary health care so it can be linked to meet the needs of its population.
“It’s not just about helping general practices and primary care more broadly to look after their patients and clients in the best way they can, but it’s also about addressing the needs of the 10 per cent of the population that don’t seek primary care services, and about taking that systems approach.”
Rio says three-quarters of Melbourne’s public housing stock is in the organisation’s catchment area, and a focus will be on better meeting the needs of high needs groups, such as refugees and homeless people.
While there are more than 8 hospitals in the catchment of her Medicare Local, Rio says Victoria has already done significant work to build better connections between hospitals and general practice. The Victorian Department of Health has funded GP liaison units in all of the hospitals. She says: “A lot of the building blocks are there anyway.”
While Rio says she is “very confident” about the future of Medicare Locals, she says one of the biggest risks they face is losing GP engagement. Another is gaining another layer of bureaucracy rather than changes that improve peoples’ health.
She says: “In our catchment area there are lots of fantastic service providers, there are lots of peak organisations and planning bodies. It’s a matter of being that enabling leverage arm and bringing them all together.
“Medicare Locals are a genuine attempt by lots of different sectors to say there are big problems here and we can move forward. It might not be the level of reform initially envisaged but it is a reforming structure.”
Education and behavioural training for high risk patients
Western Sydney Medicare Local
It’s 8.30am on a Monday morning when Rachel Barker and I chat about her work with the Western Sydney Medicare Local, and her energy and enthusiasm for her work is clearly evident.
Three years ago she left a corporate job in the CBD to take up a role with the organisation’s predecessor, WentWest, in developing a preventative health program for patients with chronic diseases, called SHAPE.
She was drawn to the job because it brought together three of her interests – social justice, marketing, and exercise science.
Barker’s role has since broadened to also work with a team that helps disadvantaged groups navigate the complexity of the health system. They take a holistic approach, and also help with problems such as housing, domestic violence and transport.
“A great example of our work is a patient who came through the Aboriginal outreach program,” she says. “He wasn’t keeping appointments, taking his scripts. Once we had the relationship and rapport with him, we found out he was illiterate. Without him coming through our program, we wouldn’t have found out. We were able to help him tap into literacy programs, and now that patient is engaged, now he does keep appointments.”
Barker has learnt that a blanket approach does not work.
“In Auburn, there are a lot of new immigrants who may have poor literacy or poor language skills whereas in Mount Druitt we have highest urban population of Aboriginal and Torres Strait Islanders,” she says. “So what is needed in Auburn from a health perspective may be quite different from what’s needed in Mount Druitt.”
She also works with a team of physiologists and dieticians on the SHAPE program, which provides education and behavioural training over 8 weeks. Patients are referred by GPs because they have chronic diseases or are overweight, and the program also works with families and mental health patients.
At present about 150 people enrolled in the program although she hopes extra funding through the Medicare Local will enable many more people to access it. Evaluations have shown a significant improvement in patients’ weight, motivation and sense of self.
Barker finds her job enormously satisfying. “I get to see the value of what good preventive health can do, from a patient perspective,” she says.
“I’ve been able to see the value of giving people the skills and knowledge to equip them to better manage their own health.
“I’ve seen first hand patients who didn’t know the fat content in a wrap they were eating on the way home from work everyday. You see their face change in the session, giving them the invaluable tools, so they now know what they are eating is actually affecting their health and their children’s health.
“The cost of someone going through the healthcare system, having a heart attack or heart disease for one patient is about $280,000. We could get 1,000 people going through our program for that amount of money. Preventative programs not only deliver a health benefits to the patient but economic cost savings to the health system in general.”
Medicare Locals can be judged a success in five years time, she says, if they make it easier for patients to navigate the system and for GPs to get the resources they need, when they need it.
In the meantime, she says she is lucky to be working with an exceptional team. “The kind of people I have on board with me, they choose to work in an area of extreme social disadvantage. A lot of them are from the region but a lot have been attracted to the region for the work.”
• Lessons from primary health care reform in the US, Australia, Canada, Denmark, The Netherlands, New Zealand, and the UK. Journal of the American Board of Family Medicine
• GPNSW and the UNSW have led a small working party to produce a Health Access and Equity Position Statement for Medicare Locals.
• In this PHCRIS article, Terry Findlay, Director of the AGPN National Transition Project, argues that the real impact of Medicare Locals will come from being part of a network, with shared learning, benchmarking, and improved efficiencies. “But the real prize,” he says, “is the ability to contribute and drive more fundamental system reforms as a high performing network overall.”
And finally a plug…
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