Medicare Locals and reform of primary care

In their joint statement about the Agreement signed at the Council of Australian Governments (COAG) meeting on 13 February 2011, the Prime Minister and the Minister for Health stated that one of the aims of the reform package was to ‘shift the centre of gravity from hospitals towards primary health care’. To that end, the Government has committed to: increasing the number of Medicare Locals (MLs) that are to be established as a result of the health package announced by the Government in March 2010, bringing forward the establishment of more MLs, fast-tracking reforms to after-hours GP care and ensuring that local communities have more information about their local primary health care services.

The National Health and Hospital Reform Commission (NHHRC) saw reform to primary care as integral to the development of a ‘person-centred’ health system. The Commission recommended significant investment in primary care infrastructure and the integration of all publicly funded primary health care services. It also advocated for Primary Health Care Organisations to take on a population health planning and service coordination role and the Commonwealth to assume policy and funding responsibility.

The proposed MLs are along the lines of what was proposed by the NHHRC. As part of the health agreement, the plan is for each ML to form part of a national network of Primary Health Care Organisations with a mandate to improve access and integration of primary health care services. MLs are to have a key role in local health planning, identification of service gaps, better targeting of services and improved linkages between the acute and aged care sector. A discussion paper about the governance and functions of MLs provided a focus for consultations conducted in the second half of 2010. The agreed boundaries for MLs (although the boundaries for Victoria have not yet been agreed) were announced prior to the February 2011 COAG meeting, yet these may change as a result of the Government’s commitment to establish more MLs.

Some states have attempted to reform primary care within their own jurisdiction. The Victorian Government introduced ‘Primary Care Partnerships’ (PCPs) in 2000. In many respects, the objectives for MLs are similar to those for the PCPs. The intention of the PCPs was to develop a more effective and more efficient primary health care system with linkages to broader health and human services system and with General Practice. In Victoria the PCPs have led to improvements in service coordination, integrated health promotion and integrated chronic disease management across Victoria.

The proposed establishment of MLs has however not been without controversy. There have been criticisms about the appropriateness of the name and, perhaps more importantly, concerns have been raised about the lack of clarity about what is considered ‘primary care’ and how primary care (and MLs in particular) will be integrated with other parts of the health care system. Others have argued that the concept does not adequately acknowledge the role of General Practitioners in the provision of primary care. The proposal has also been described as a missed opportunity for the implementation of ‘true primary care’ which is multi-disciplinary in approach and delivers both illness prevention and health promotion. These issues were not addressed in the discussion paper, and, to date, the Government has not reported on the consultation process.

The proposal to establish additional MLs as part of the new health deal has therefore also had a mixed response. The Chair of the Australian General Practice Network (AGPN), Emil Djakic suggested that if the boundaries were redrawn, it would be difficult for participating organisations to meet the 1 July implementation date. In response to media reports about increased MLs for Victoria, he argued that any increases to the number of MLs would weaken the proposed national structure.

The new package falls short of the NHHC’s (and the Government’s initial) proposal that the Commonwealth assume full funding and policy responsibility for primary care. Yet the chair of the NHHRC has provided some support for improving the delivery of primary care, considering it to be ‘linchpin’ of any health reform, and full funding as 'something we can work towards'. Under the February 2011 Agreement, roles remain largely unchanged with the Commonwealth having the ‘lead role’ in delivering primary health care reform and the States responsibility for service delivery. While there is a clause in the Agreement about the States and the Commonwealth working together on ‘system wide’ policy to achieve better integration between State and Commonwealth funded services, there is little detail about the mechanisms to achieve this, suggesting that the agenda to advance primary care has yet to be articulated, or even agreed to.

The Government’s proposals for MLs as presented in the consultation paper and the Victorian experience with PCPs, might lead us to expect that MLs will lead to greater coordination and integration of local primary health care services. Yet, the task of integration is not well defined and will require participation from multiple agencies each with different goals and agendas. Research into PCPs in Victoria highlights the complexity of collaboration. It notes that for organisations to work collaboratively they must be willing to give up some control over their actions and potentially be affected, adversely or otherwise, by the consequences of the activities of other organisations. It also noted that trust was integral to effective relationships and, further, effective relationships were integral to improved outcomes for clients.

How MLs will operate will therefore be critical. Questions have already been asked about whether MLs have sufficient funding to achieve their objectives. At this stage there is very little detail about how they will work, what the accountability frameworks might be or their relationship with the proposed governance structures of the health package. It is expected that MLs will be established as companies limited by guarantee formed by a small number of initial members. Adequate representation is likely to be critical to achieve integration of primary care across a range of service providers. In Victoria, each PCP has ‘core members’ including hospitals, community health, local government and divisions of general practice. Other organisations can also join the PCP. The core members represent the majority of primary care providers in a local area and there are sufficient incentives to ensure that key primary care organisations participate in the PCP. Currently, no such frameworks exist for MLs, and this may need to be addressed so that MLs can achieve their objectives.

As the PM noted, there are many details yet to be resolved in the health reform package. And it will take some time for the reforms to be institutionalised. Initially MLs will have responsibility for the coordination of the reforms to improve access to GPs after hours. Much therefore remains to be done before MLs will be able to achieve improved integration of primary care services in a local area and reorient the health system towards primary health care.

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