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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 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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  • 1
    Gavin Mooney
    Posted November 20, 2012 at 7:44 pm | Permalink

    “What people with chronic problems need to hear … is how services will be organised for them, not the other way round, in future.” Right on Steve! This is the challenge of Medicare Locals – not easy but about time in PHC. Health services are first and foremost social institutions and MLs at last and at least recognise that.

    Australia previously struggled in primary care with the all too many, all too small and all too resource poor “Divisions’ (almost as bad a name as Medicare Locals!). At least the philosophy behind MLs is right. And if the Social Determinants of Health are going to take off in Australia – and isn’t it about time? – the MLs are the bodies to lead that.

    My main worry on MLs is simply: will Canberra really let them be ‘local’?

    (It was her predecessor who gave them them the unfortunate name but can Tanya Plibersek now change the name please? I phoned one today and got an automated message saying in essence “Don’t come to us for your Medicare money, ring XXXX”!)

  • 2
    Margelis George
    Posted November 21, 2012 at 8:23 pm | Permalink

    The big problem is that Medicare Locals do not include the entire health system, and the Local Health Districts or Networks depending on what state you are in operate in isolation of the Medicare Locals. In the USA the Accountable Care Organisations combine hospital and primary care and force them to both have combined goals, forcing them to work together. Whilst there is good intent between many MLs and LHDs the reality is that without systematic collaboration between them they will not be able to deliver.
    Whilst they remain structurally separate, they should at least aim for functional integration by linking up their information systems. Potentially the PCEHR may provide the infrastructure to do this, but it will require the relevant groups to take a much more active role in its future development. This will require them to be become much more active in the ehealth space, possibly replacing the current board of NEHTA with representatives of the MLs and LHDs to replace the current state and federal health department leads.

  • 3
    See Limes
    Posted December 6, 2012 at 8:01 am | Permalink

    “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.”

    WTF? If I as a rural doctor have to answer the phone at 2am every night, I am going to be too buggered to work the next day…so cancelling the 40 or so people I am supposed to be seeing in my Clinic. medicare won’t pay me for a phone consult…and the insurers will have a hard time defending me if I make a wrong diagnosis over the phone – is this patients shortness of breath anxiety? Or life-threatening asthma? A PE? Heart failure?

    No evidence that phone advice lines work – indeed some emerging evidence that they INCREASE health costs and ED presentations

    No incentive for rural docs to engage in increased after hours…especially when the cost of doing so means the collapse of their ability to work next day

    All seems a bit pie in the sky, frankly. I reckon most sensible rural docs will walk away from Medicare Locals and after hours service provision

  • 4
    Gavin Mooney
    Posted December 6, 2012 at 2:47 pm | Permalink

    OK “See Limes” I can understand your position. But what do you suggest for someone like me who lives in a rural area and might need medical assistance at 2am? There needs to be some way of dealing with this other than walking away from it. This is not a new situation and MLs are at least charged with trying to do something to address it. What is your solution?

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