The Federal Government talks much about shifting funding to “frontline services – where people need them”. It sounds obvious, until we look at what’s lost from the backline.
In the first of two posts below, doctor and lawyer Dr Fiona Lander looks at new restrictions on law reform advocacy by community legal centres (CLCs). Noting the findings of the landmark Legal Australia-Wide Survey, she considers how this shift might increase unmet need and therefore bigger issues later, particularly for the most vulnerable people, and says it reflects a worrying trend towards abolition of preventive services in various sectors across the nation.
In the second post, Walter Kmet, CEO of WentWest argues that we need to look at how we define frontline health services, and particularly whether the definition should include primary prevention and care navigation:
We know that a lot of what general practice does on a day-to-day basis, such as proactive disease screening and helping their patients make choices about their care needs, falls into these categories of care but they are absorbed in a siloed fee-for-service system.
Dr Fiona Lander writes:
Changes to legal advocacy funding: the link with health
From 1 July 2014 onwards, any funding that community legal centres (CLCs) receive from the Australian Government will be limited to expenditure on delivery of “frontline services”. The service agreements in place between affected organisations and the Commonwealth will include a requirement that CLCs will not engage in law reform advocacy using Commonwealth funds.
These restrictions on spending have raised the ire of many in the community legal sector. Community Law Australia has rejected the new restrictions, labeling them “damaging and counter-productive” noting that law reform and policy work are a small, but vital, aspect of community legal work.
The justification for this limitation offered by George Brandis, the Federal Attorney General, is that the decreasing funds available for legal services due to resource constraints should only be used for service delivery. Around $15 million in cuts have been made to the nationwide Legal Aid budget, with a further $6 million to be cut from community legal centre funding in 2017-2018.
The concern of those working in CLCs, and many other commentators, is that these changes may actually lead to increased unmet legal need, given the value that is added by the sector in terms of its law reform activities.
However, these changes may also indirectly impact negatively on the health of our society’s most vulnerable people, and reflect a worrying trend towards abolition of preventive services in various sectors across the nation.
Prevention versus cure
The debate that rages over expenditure division between policy work and service delivery is not new and is not confined to the legal sector. The same issues constantly arise in the healthcare sector.
There are a number of reasons why it is easier – and politically more palatable – to focus on delivery of medical, legal or other services at the expense of broader systems reform.
Firstly, there is (arguably) a moral imperative to assist as many people as possible right now, even at the expense of those whose problems will be prevented in the future through diversion of funds from “frontline services” to preventive activities. Of course, this argument assumes that there is a finite amount of resources available for the particular sector in question, and that overall funding cannot be increased to provide a service and engage in preventive or advocacy-related activities.
Secondly, it is challenging to justify diverting public funds to activities with uncertain outcomes. It is comforting to look over expenditure figures that indicate a service has been delivered to a certain number of people, whether it be in numbers of hospital beds filled, or numbers of clients provided with a legal service, where a clear, measurable and welcome outcome is demonstrated. By way of contrast, advocacy-based activities are not necessarily going to result in widespread change – although they often do.
Thirdly, even if advocacy and agitation for law reform are effective, the effects of these activities can be incredibly difficult to measure, similarly to other preventive interventions utilised in fields like public health. For instance, the example given by The Guardian of the proposed changes to the federal electoral rolls to conceal voters’ divisions, to prevent location of victims of family violence, are no doubt vital and long overdue.
But how can the impact of such a change be meaningfully measured and claimed by CLCs as a direct outcome they have produced through federal funds? Can we meaningfully measure the number of episodes of violence avoided by the implementation of these reforms? The reality is that it is difficult to do so.
Nevertheless, a recent comprehensive investigation into access to justice concludes that such law reform activities are effective. The Productivity Commission has recently released a draft report on its enquiry into Access to Justice Arrangements, which states that advocacy activities form a vital aspect of CLCs’ activities.
The draft report notes that strategic advocacy is an area where there are few incentives for private lawyers to act, predominately because they cannot charge for activities that benefit the whole community. Strategic advocacy by CLCs, on the other hand, can be “an efficient use of limited resources”.
A number of examples cited in this report demonstrate the value of strategic advocacy in assisting groups of clients simultaneously, resulting in cost savings. Victoria Legal Aid noted that:
‘When done effectively, strategic advocacy can create significant savings not simply for the legal assistance sector but also a cascading impact on other agencies. This includes improving primary decision making providing government with the advantages that flow from getting a decision right the first time and short-circuiting the duplication and delay caused by poorly made decisions.’
From a health perspective, there is a genuine concern that cessation of these advocacy activities will detrimentally impact upon people who are already vulnerable.
The reality is that particular groups who are experiencing multiple legal problems are more often than not the same groups that are at risk of poor health. Legal problems not only cause poor health, they can also be caused by health issues, such as mental illness. Moreover, the “social determinants of health” model acknowledges the various conditions that lead to people experiencing poor health – these include financial and legal stressors.
In the landmark Legal Australia-Wide Survey conducted by the Law and Justice Foundation of New South Wales in 2012, it was found that the subsets of people experiencing multiple legal problems – and the types of legal problem they experienced – were not random. In fact, there was “considerable consistency” in the legal problems that people experienced concurrently or in quick succession.
Around 9 per cent of survey respondents accounted for a whopping 65 per cent of the legal problems reported in the survey. This is not coincidental – certain groups in society were identified that are particularly vulnerable to experiencing legal problems, such as people living with disabilities (including mental illness), Indigenous people, the unemployed, single parents, and those living in public housing or dependent on welfare.
Two of the three most common adverse consequences resulting from the legal problems reported in the survey were health-related: 20 per cent of respondents reported stress-related illness, with 19 per cent reporting physical ill-health, as a result of their legal proceedings. The only problem that was more frequently reported was income loss or financial strain (29 per cent) which itself contributes indirectly to poor health.
Taking a longer-term strategic approach to preventing and managing multiple legal problems is almost certainly more cost-effective, both in terms of legal, health and other interventions, than simply delivering frontline services to people who self-present to CLCs. Restricting the ability of CLCs to address the underlying causes of these legal problems will necessarily have pernicious flow-on effects that will result in negative outcomes – including poorer health.
A worrying trend?
Unfortunately, these changes to service agreements with CLCs reflect a broader trend on the part of the current government towards restriction of many “preventive” activities of government or non-profit agencies.
Various public health agencies and agreements that aim to decrease disease burden in Australia have been abolished. The National Preventive Health Agency, National Partnership Agreement on Preventive Health, and the Alcohol and Other Drugs Council have all been the victims of cuts in the recent Federal budget.
The short-sighted nature of these changes is disturbing, and we may not feel the effects for many years. The immediate cost savings that are made through these cuts will surely outstripped by the increased expenditure required in the future on the “frontline” services Brandis currently prioritises.
Dr Fiona Lander is a qualified medical doctor and lawyer. Her main areas of interest include health, human rights and public health law. Dr Lander has worked for Anand Grover, the United Nations Special Rapporteur on the Right to Health.
Walter Kmet writes:
Frontline services, what do we mean?
In recent times the term “frontline service” has become very much associated with what might be defined as a good and appropriate investment of health dollars. Akin to an investment in “doctors and nurses”, which might be an older version of the same thing, one could be led to believe if we are not investing in frontline services we are wasting our money. This raises the obvious question: how one might define frontline services and indeed is this all that we need invest in.
Let us look at hospitals, for example, where no frontline services, however they are defined, could be provided without very significant soft and hard infrastructure. We hear little argument that when hospital infrastructure investments are made they are not needed. They are accepted as cost of doing business and, for private operators, require a return on investment.
However, when similar system infrastructure is contemplated at the primary care level it is often baulked at or seen as a secondary priority. If we look across the general practice landscape there is an obvious need to invest in more contemporary hard infrastructure but also soft infrastructure, such as capacity and capability building in general practice and allied health, and investment in creating better pathways across a fragmented health system.
There is often no defined and long-term plan or budget for such system infrastructure in primary care even though it will provide obvious benefits, not in the least strengthening primary care as a comprehensive medical home for patients.
We should also question whether a contemporary definition of frontline services should include primary prevention and care navigation. We know that a lot of what general practice does on a day-to-day basis, such as proactive disease screening and helping their patients make choices about their care needs, falls into these categories of care but they are absorbed in a siloed fee-for-service system.
These interventions properly defined and paid for have the effect of avoiding the use of more expensive hospital-based frontline services. They have the potential to improve overall health outcomes while at the same time directing care to more appropriate and often cheaper alternatives. So they are good investments.
Getting the definition of what we mean by a frontline service, determining the need and effectiveness of that service, and at what level such investment should be made, is critical. The policy framework in this area will drive decisions about future investment at many levels of the health system. In addition and with reference to a limited “bucket” of health funds it sets the stage for a proper debate about the balance of health investment. This is currently strongly weighted towards the frontline services and their infrastructure that are provided within hospitals, not what might support them in the frontline of the community.
A well thought out policy approach will mean that primary care can better support efforts to integrate patient care. For example when we look to the future workings of our health system little is said about the need for risk stratification; ensuring that we properly understand and assess a patients patient’s health conditions and risks so that services or interventions to improve the persons outlook are well targeted.
In addition there is a tendency for “referral medicine” to occur; where a patient is pushed off to various parts of a disconnected health system when well organised primary care based navigation would lead to better continuity of care and it would be also save money. These functions rarely figure in what might be defined as a frontline service, but they are none the less desperately needed so that the system can be effective in allocating scare resources.
In other cases it may mean funding in different ways so as to invest in reducing access barriers faced by many in the community. The Royal Australian College of General Practice (RACGP), in its 2014 Budget submission, began making a case for a shift in this area. It argues that work is needed to: “to develop a sustainable, equitable, effective, and efficient funding model to support GPs and primary healthcare to deliver patient care via the medical home.”
Therefore we not only need to avoid reimbursement system changes that will drive even more time-based volume behaviours to compensate for these mostly inadequate time-based reimbursements, but we do need policy development and debate so as to lead the system to more effective systems being rolled out. This could include a broadening of how we pay for care to incorporate genuine team care arrangements based around general practice, encouraging continuity of care, not quick episodes of care.
This will mean accepting that we have to define care beyond simple patient facing interactions and ensure that good care planning and system infrastructure is in place to ensure it functions effectively. It could, for example, include defining and funding team based care arrangements for certain chronic conditions and paying for this as a whole, not as a series of individual parts.
This considers the fact that the burden of chronic and complex social diseases is increasing and we are swimming against the tide using the definitions of care and their payments systems that were developed for very different times.
If the focus of policy is frontline service provision, the health economy will continue to find an obvious response: there will be more frontline services. So if we are going to base our health system on delivering frontline services we need to ensure everyone knows exactly what that means and that we can be assured we need them. This will form the basis for future investment decisions which are most effective.
Walter Kmet is CEO of WentWest and Adjunct Associate Professor at the University of Western Sydney.