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Nov 20, 2012

Glib lines on Medicare Locals won’t resolve chronic ills

The chronically-ill vote too and their expanding demand for primary care services should be kept in mind at the next election. That advice comes from long time public health advocate

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The chronically-ill vote too and their expanding demand for primary care services should be kept in mind at the next election.

That advice comes from long time public health advocate and scholar, Stephen Leeder.  He is calling for more sophisticated thinking
about Medicare Locals rather than dismissing them as another useless layer of bureaucracy.

“This Romney-esque line is too glib and too simple by half  to be useful or convincing, says Professor Leeder.

What people with chronic problems, many of whom voted, needed to hear was how services would be organised for them, not the other way  round, in future.

His comments come amid uncertainty about what a Coalition Government would do about Medicare Locals.

Opposition health spokesman, Peter Dutton, has been generally critical of Medicare Locals.    His  junior, shadow parliamentary spokesman on primary care, Andrew Southcott, said recently a Coalition Government would not  continue with the current structure.  But  Dr Southcott also said: “There are some very impressive Medicare Locals. ”


Tough tasks ahead for primary care

Stephen Leeder writes

The health services  literature contains accounts of many effective ways of organising care for  people with serious and continuing illness (non-communicable diseases including  heart disease, respiratory disorders, diabetes and cancer).

The common features of these approaches include linking  hospital care and community care and specialist services with general
practitioner and allied health professional support. All depend upon the  majority of care being given and managed by family and friends with support from  community services.

Communication channels must be open, effective, have  in-built redundancy for emergencies and be humane (oft forgotten).

The reorganisation of current health services, with the  separation of funding streams for hospitals and general practitioners, and
low-level communication systems among these players and patients and carers, is an immediate challenge because of increasing prevalence of chronic problems.

Without service linkage, hospitals and community services end up providing care for which they are inappropriate.

The patient with chronic lung problems who panics at 2am because of breathlessness is less likely to require ambulance and emergency
department care if his or her panic attack can be handled over the phone by a nurse or doctor who knows them and can support them through it.

People with clear-cut end-of-life advance directives are  more likely to have these considered seriously in hospital if the treating
doctor is clear about and there is unequivocal documentation available on line to him or her to inform all care decisions.

Australia has a long way to go in achieving an ideal service configuration to  achieve this care. Small steps are leading to the personally controlled  electronic medical record. Hospital services are increasingly deployed beyond their walls and in communities.

Communication is better than decades ago, but it is  debatable whether humane concern and clear conversation that puts the patient
at the centre of everything are more prevalent.

Medicare Locals – primary health care organisations – that  link general practitioners to the extensive network of community allied health  services, are coming on line but struggle because of novelty, very low  (comparative to hospitals) budgets, and the load placed on them.

Hard tasks, such as  prevention and mental health care, are assigned to them as though they had  magical powers. They are new and it will be several years before their full  service impact can be assessed.

The fragments of  evidence available to us about the effectiveness of linked-up support of  general practice from other community services is encouraging.

With alternative health service arrangements on offer in the forthcoming federal election, we should be asking the contestants to explain
how they will overcome the perversity of funding arrangements that keep general practice, community services and hospital care isolated from one another and  prevent the easy transfer of funds to the most efficient care provider given a particular health problem.

The march of demography, especially the ageing of the  population and the growing burden of non-communicable disease, suggests the
need for more sophisticated approaches than are found in threats to ‘abolish Medicare Locals because they are another useless layer of bureaucracy.’

This Romney-esque line is too glib and too simple by half to be useful or convincing.

What people with chronic problems need to hear – and there are lots of them and many of them vote – is how services will be organised for  them, not the other way round, in future. Central to these services is an effective, linked-up world of general practice and community care.

Let’s have a serious discussion about that.

Stephen Leeder is Professor of Public Health and Community Medicine and Director of the Menzies Centre for Health Policy, School of Public  Health, and Sydney University.  He is also Chair, Western Sydney Local Health District Board and Director, Research
Network, Western Sydney Local Health District.


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