President's Blog, Friday 25 March 2011
The Problems With Medicare Locals
The AMA has gone public with a position of strong opposition to the Government’s Medicare Locals as currently proposed.
We have called on the Government to defer the establishment of any primary health care organisations (PHCO) until there has been genuine consultation with the medical profession.
The AMA has for some time been calling for consultation and more detail about the governance and operation of Medicare Locals, but those calls have been met with silence.
The AMA cannot support primary care reforms that do not explain how they would benefit patients or communities, and which do not guarantee they would maintain and support the leadership role of GPs in primary care.
There must be meaningful dialogue with the medical profession about a way ahead that is best for patient care.
The AMA is not opposing the concept of a primary health care organisation to coordinate primary care services.
When Medicare Locals were first announced we were cautiously optimistic about the role they might play in improving health care for Australians.
But since that time there has been little detail about governance, funding arrangements, or the envisaged role of doctors in their management. It is a big ask for us to support a vacuum.
Some commentators seem concerned that the AMA insists that doctors should be strongly represented on the governance structures of our health systems.
You need only look at the chaos wrought upon our public hospitals when they are administered without appropriate reference to the doctors (and other health workers) who actually deliver the health services in the hospitals.
New Zealand’s initial experience with PHCOs that were supposedly run by ‘skills based’ boards was heading for disaster until the situation was retrieved by an increased presence of doctors on those boards.
Locally, we examined closely how the proposed Medicare Locals were intended to integrate with Local Hospital Networks. Our examination was not too encouraging – hence our concerns.
Medicare Locals will be funded separately, governed separately, and will function separately to the acute hospital system.
The chances of evolving a Medicare Local-inspired integrated health system are just about zero.
The likelihood of continued cost and blame shifting between the Commonwealth and the States is extremely high.
Like it or not, the assumption that health care is improved by marginalising the role of doctors in decision-making is, to say the least, contestable - and the AMA will certainly continue to argue against it.
The AMA Position Statement on Medicare Locals can be found here.
What do you think of Medicare Locals? Share your views with us here.
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anachronistic words
I refer to the constant " patient care".
Doctors TREAT PEOPLE.
That's it. Social workers "care" for people. Sure medicine is within the group of "caring" HPs. E/C of medical groups were successfully dudded by the politics of the AHP groups over recent decades. They "care", we "treat". Funny that. Doctors lost the PR battle in the 1980s which the AHPs won [ with intro of RSPs and the RSI catastrophe, in which everyone lost; i mean everyone [ I'm avoiding the trendy word "stakeholders"].
Worse than the "care" word, is persisting use of the word "patient". one does not need a generic word at all; the word "people" is OK. Readers would get to understand tis in a week or two. I dislike the other synonyms just as much, but in our [evil] "fee-for-service" system ,the word "customer" is the most accurate. I point out that medical treatment is a commercial contract, whether one likes it or not. [ It is still commercial when a third party pays].
Also unpalatible as it is doctors, to label a person a "patient" who may seek, or actually obtains medical treatment [or advice or something outside of actual help], is unnecessary and heirarchical and worse patronising. Anachronistic etc.
marginalising doctors
Would anybody or any organisation, or even any bureaucrat in their right mind suggest, for example, marginalising motor mechanics when it comes to organising the workings of car maintenance schedules and organisations? How can it possibly be helpful to exclude, near as dammit, the professionals in any field of expertise from the organisation of provision of services in that field?
The problem however is of OUR making! WE are the sole providers of an essential service so who do we have to blame if we are not listened to? All we need to do is refuse to co-operate with schemes which our professional training and expertise tells us are less than optimal. We don't have to be radical, just firm.
This is contrary to the personality of most doctors who are on the whole non assertive. However nothing happens in the comfort zone and until we are prepared to demonstrate the backbone to get out of our comfort zone we will continue to work against the interests of our patients. How many times have doctors' lack of action led to long term disadvantage to the public because at the time the doctors were not prepared to "disadvantage our patients?" It's time doctors stopped behaving like cats being herded when it comes to working together for the common good.
And I don't agree with Tony Lowy. The clientele of doctors have traditionally been called "patients." The modern trend to call them "clients" is a left wing pinko attempt to reduce the standing of doctors and to devalue the particular privileged relationship that exists. Nor is Tony quite right when he says the doctor /patient relationship is a commercial contract. There often is a commercial element to it but there may not be, for example if one chooses not to charge a fee. There always is, however, a moral and ethical contract. That's where problems exist with socialising medicine. In private practice the contract is between patient and doctor, in public medicine the contract is between patient and government health department. Money has nothing to do with the contract except that the government has a financial contract with the doctors whom it employs to actually provide a service.
Medicare Locals
There is little doubt that Medicare Locals should exist to support the 'grass roots' primary health providers. This, at least in my belief, should include practice nurses and nurse practitioners Therefore, although it is easy to ask for these bodies these bodies to be GP led, it is the mix of those involved that will give the best outcome. These locals are not divisions of general practice... they were for GPs by GPs. These ought to have a wider spread of involved people BUT they should be led by 'health care professionals' guided by community and other groups. NOT the other way round.
Medicare locals
In reply to David Dammery, our experience in O&G is that midwives are a very valuable resource and do a brilliant job, but evidence of the obvious is now beginning to emerge in the literature, that midwives practicintg independently cause disasters. As part of the obstetrician led team they are brilliant. I am sure it is the same in general practice of which I have had several years experience. Good nurses working in the practice are worth their weight in gold, but the leadership must be the most qualified, in this case the GP. I say again, the GP. Not just some unspecified "health care professional."
medicare locals
I am a GP of 42 years standing
I have worked in general Practice all this time, initially in the suburbs and now in the city.
I am interested in caring for my patients and offering them the best medical help available
There is no way any system about primary care of patients can function without the GP as the starting point and the hub of their care.
Patients complain constantly about lack of continuity of care and without the GP at the centre of their medical management, there can be no continuity of care.
One knows from experience that you can solve your own patients ' problems in a far shorter time and with greater expertise because you "know" the patient, than have them present to a "casualty" or another facility where there is no "Knowledge of the Person"
In a short conversation one can tell a collegue all about the "person" and hence expediate their care
This will not happen with any perceived "system" that precludes the general practitioner
The role of Medicare Locals
I am a GP registrar and was lucky enough to attend a discussion with our local Division of GP's (Riverina division) on what the Medicare Local proposal would look like if we were chosen as a pilot site. The initial start-up proposal really didn't look much different to the existing division of GP's, only with slightly more admin and a different name. The envisaged progression to a more fully comprehensive meeting point for health care, including mental health and aged care, is definately necessary and I support it 100% - BUT on discussion with the division, that side of the Medicare Local function will only be rolled out after the initial stages are complete, and there is as yet no agreement from the state government that they will hand over the funding or administration of these 2 sectors to the medicare locals.
I left feeling somewhat discouraged that yet again we have a million dollar investment in re-branding without clear direction on the most important step, which is to integrate mental health and aged care so that patients no longer fall into the gap. Until the planning for this stage of the medicare locals is at least provisionally sorted out (with definite timelines for transition locked in so they're not dependent upon who is in parliament!) I don't feel the medicare locals will offer anything new compared to the current divisions. This for me is the bigger issue.
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