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Dr Hemley's speech to AMA National Conference on Medicare Locals

AMA Victoria President Dr Harry Hemley's speech to AMA National Conference on Medicare Locals (28 May 2011)

Firstly I would like to thank you for the opportunity to discuss this vitally important issue and to thank the previous speaker for his views.

Health planners and economists have done much for this country.

They have delivered doctor shortages, bed shortages, long waiting lists, the demise of our aged care sector and domiciliary medical services.

All whilst delivering cuts in the PBS, MBS and increasing the out of pocket spend on health by the Australian people.

They have also delivered more bureaucracy, propagating red tape, strangling quality patient care 

And now?

Medicare Locals , Primary health care organisations/Commonwealth area health boards by stealth, A vehicle similar to the discredited UK style fund holding model, now abandoned as inefficient, ineffective, and inhumane — delivering poor patient outcomes.

There are three key things to remember about Medicare Locals:

  1. They will not be like Divisions of General Practice.

  2. They will create additional bureaucracy and red tape

  3. Patients’ care is best coordinated from doctors’ practices — not by a bureaucracy

In 1992 the Keating Government introduced Divisions of General Practice. They receive over $250 million yearly in infrastructure support as well over $120 million a year in other funding. They employ about 3000 staff. 

Most of this funding was taken from patient Medicare rebates.

Governed by GP’s they had some significant successes like the national child immunisation program. But whether high performing or not; in the bureaucrats eyes, they had one problem — they were governed by GP’s.

So as was said by a previous health minister...”It’s time for Divisions to grow up”

That meant Primary Health Care Organisations (also known as Medicare Locals) — fund holding vehicles with broad based boards of lawyers, accountants and health economists plus of course the odd consumer tag along puppet.

Nowhere in the tender document are GP’s included.

Those Divisional supporters / Medicare Local GP aspirants can be assured — you are selling out your GP colleagues and the communities they serve by touting the benefits of these PHCO’s.

Unlike divisions — Medicare Locals will not have meaningful GP representation on the boards.

So what do we know about these Medicare Locals?

We know that the Government wants Medicare Locals with their 2500 staff to interact with any number of other bureaucracies.

Bureaucrats talking to bureaucrats.

The first 15 will be launched in July this year. Then the remaining 42 will follow soon after.

The setup fee?

$477 million offset by the dissolution of GP Divisions.

They will also receive ongoing infrastructure funding of $171 million per year.

As well as holding funds of $548.8 million over 5 years to provide co-ordinated care for patients with severe and persistent mental illness through Non Government organisations

 $205.9 million over 5 years to provide access to allied psychological services.

They will also receive yet unspecified funds for services to the aged.

This Bureaucratic white elephant all comes at a time when Government is gutting the PBS, MBS and failing to invest adequately in the training of our young doctors.

Increasing numbers of complex elderly, mentally ill patients are coming through the GP’s door every day.

They need more and better co-ordinated care.

I don’t see how wasting busy GP’s time setting up yet another bureaucracy with more forms, more charts, more phone calls, and more conversations will actually improve the patient’s access to medical care and health outcomes.

The only ones to benefit are those working in the medicare local bureaucracy and the NGO’s which receive their funding.

On the contrary, when I see an old patient of mine enter my over full waiting room for the first time with a care provider, my heart sinks, as I know it will take 3 times longer including more explanations and instructions, extra forms, charts, owed scripts and telephone conversations.

The Prime Minister indicated in the February COAG agreement that Medicare Locals were to:

1)      Help patients to co-ordinate their care and navigate the healthcare system

2)      Improve access to after hours care

3)      Identify local healthcare needs and service gaps.

Lets talk about Identify and address local service needs and gaps.

One Medicare local in Tasmania, One in Northern territory, One for the Act, 6 in Western Australia, 15 in Victoria, 17 in NSW, 5 in SA, 11 in QLD – hardly local.

Besides, there are already many Government bodies, Federal, State and Local which collect health data and identify service gaps.

Why duplicate these with further data collection and yet another layer of bureaucracy?

We in our general practices have the capacity to identify an individual patient’s health service gap through our own knowledge of the patient.

What about after hours care?

As a young doctor, I did a lot of moonlighting trying to earn an extra dollar to support my young family.

I’ve done after hours with Locum services and in a big Group Practice for years as well as visiting the homeless poor and the elderly in their homes and in the aged care facilities.

I’ve also done a few bush stints.

In all of this as with many GP’s I am available on the phone after hours.

This is one way that patients may have access to their doctor after hours.

There are a myriad of arrangements which exist throughout the country, despite a lack of adequate commitment from government.

Medicare Locals will not perform one extra after hours service. The Government has said — Medicare Locals will not be involved in service delivery.

The government itself implicitly has recognised the importance of the GP in after hours service delivery by extending the after hours PI P until 2013.

At this time $75 million after hours PIP funding will be taken from General Practice and rolled into an as yet unspecified $120 million model of after hours service delivery.

Separate to that, a national GP triage will be set up.

How will a doctor 600 Km away be able to advise a patient they do not know   about services locally of which they have little if any knowledge?

And who will visit the old and infirmed in the aged care facilities or do home visits to those unable to make it to the emergency department or what ever after hours clinic is set up?

Who you gonna call — “The Ambulance”?

And what will the arrangements be for our rural colleagues?

What will happen to the myriad of local services which exist throughout the country?

Finally, it was said that Medicare Locals will ”help patient’s co-ordinate their care and navigate the health care system”.

So what is this co-ordinating navigating role that this expensive bureaucratic medicare local fund holding juggernaut going to do?

My understanding is that they will be rationing funding for the patients I’ve previously mentioned, the heart sinks; the elderly infirmed mentally ill, chronically ill obese intellectually impaired COPD and so forth.

Rationing funds to the very people who have difficulties dealing with bureaucracy.

So who does the patient turn to?

Why of course, their trusted GP, to fill in the forms, give the instructions make the calls...what can I say more bureaucracy more red tape.

Better employ another bureaucrat to triage with the calls and format the forms.

A big waste of money, not one extra service and more barriers to the care they need

I love this one. It’s a promo for Medicare Locals, a case vignette from the Federal department of health and Aging describing.

“Kylie, a 44 year old Aboriginal woman living in central Queensland who has become depressed‘. Using her Aboriginal Health care Centre in Partnership with her Medicare Local is able to access psychological support.”

This is exactly the type of patient who may struggle to get access to a telephone let alone navigate the bureaucracy of a Medicare local.

Hence the local aboriginal health service is doing the real leg work.

So why not fund the Aboriginal Health Service directly rather employing a distant bureaucrat to ration and approve the service?

I don’t know about you, but every day. I, and other GP’s, help patients navigate our complex health care system.

Government is a bit blind when it comes to the private side of things but it is worth acknowledging the myriad of small private allied health workers within our communities most of whom are not funded by government and yet with whom GP’s must co-ordinate patient care with every day.

General Practice has a co-ordinating role with most of these as well as the government funded public services and public and private hospitals and specialists.

The alternative model

People are living longer; we are seeing more complex and difficult patients.

Certainly within local communities in big cities, there are a plethora of service providers.

The Public Hospitals are over burdened and the privates now days often cherry pick.

In order to navigate the health system, our chronically ill infirmed patients need support from local people who know the local services and service providers; who know local transport systems and subsidies and know local families and ethnic groups and their relationships to one another.

As a rule the experienced local GP knows all of this.

Our Model put forward by AMA Victoria is an innovative model based on case co-ordination support staff located within general practices.

Its value has been recognised by the Victorian State Government, which has put aside funds in its recent budget to support a pilot program.

Working alongside GP’s, case co-ordination staff with the knowledge of the patient’s needs and knowledge of the local healthcare environment will bring together all of the local services in a co-ordinated fashion under the direction of the GP in a team care environment and under the same roof.

The simplicity of this model reduces the burden of red tape and improves the patient’s access to medical care

This model of care achieves simply what the bureaucratic juggernaut of Medicare Locals could never achieve.

For instance

A GP practice in Victoria Street Richmond in Melbourne (colloquially called “Little Saigon”) might employ a  Vietnamese Case support co-ordinator.

This support co-ordinator might organise appointments, work with families and other carers, follow up reminders, liaise with pharmacies, arrange ACAT assessments, SAAP and HACC services and so on.

All under the direction of the patient’s doctor.

Although proposed by AMA Victoria, this model has it’s genesis from the many sons and daughters, nieces and nephews, fathers and mothers, and so forth who have been at their wits end trying to navigate a complex health system for sick a debilitated family member, not knowing what to do or who to approach other than their own family doctor.

It is a simple cost efficient, flexible model which has proven evidence internationally as not only improving health outcomes but reducing costs in terms of reduced hospital admissions and complications.

It would be a considerable saving on the huge outlays already described in the establishment and maintenance of Medicare Locals and leave plenty left over for education and training of our young doctors as well as allowing for further infrastructure for training facilities in General practices

So why would the Gillard Government want to spend all this money setting up another bureaucracy, against the advice of the medical profession?

The prime minister has said unequivocally, that fund holding is a central role of Medicare Locals

Why is AMA opposed to fund holding? What’s the problem?

From where I am standing, my job is to provide the best care I can for the patient.

Of course we all take into account the patient’s capacity to pay and advise in that respect, but at the end of day the government is held to account

Just as we say the patient must take significant responsibility for their own health, so must the government take significant responsibility for its citizen’s access to health

Fund holding rations care.

For our patient’s, our job is to provide the best care we can in the circumstances.

So remember,

  1. Medicare Locals will not be like Divisions of General Practice.
  2. Medicare Locals will create additional bureaucracy and red tape which will compromise patient care.
  3. Patients’ care is best coordinated from doctors’ practices — not by a Medicare Local bureaucracies

We can advise government and it can ignore us at its peril.

Our health system has stood the test of time.

Medicare Locals will produce barriers to patient care.

General Practice must be supported to provide better patient coordinated care.

Right care right time right place.

Thank you.

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