Primary Care Organisations:

promise and performance

Mark Harris, Centre for Primary Health Care and Equity

Note: The author is a Director of Inner West Sydney Medicare Local.

The Centre for Primary Health Care and Equity has contributed to a recent

Evaluation of Medicare Locals. This talk contains no material from or

reference to this evaluation which is confidential. It is based on publicly

available information.

Centre for Primary Health Care and Equity

Outline

• Historical and international context

• Objectives of Medicare Locals

• Perceived performance

Aim: To review the objectives & performance

of primary care organisations

Centre for Primary Health Care and Equity

Divisions of General Practice

• The purpose of the Divisions Program was to provide

services and support to general practice at the local level to

achieve better health outcomes for the community

• Divisions conducted a wide range of activities, such as

providing support for practice accreditation, practice nurses

and introduction of electronic medical records which helped

to transform the organisation and infrastructure of general

practice .

• However despite some success in diabetes shared care,

Divisions demonstrated less impact on clinical performance

in key areas of prevention and management of chronic

disease.

–Scott A, Coote W. Health Econ. 2010 Jun;19(6):716-29.

Centre for Primary Health Care and Equity

National Health and Hospital

Reform Commission 2009

Enhance service coordination and population health planning priorities

at the local level through the establishment of Primary Health Care

Organisations, evolving from or replacing the existing Divisions of

General Practice. These organisations will need to

• have appropriate governance to reflect the diversity of clinicians and

services forming comprehensive primary health care;

• be of an appropriate size to provide efficient and effective

coordination (say approximately 250 000 to 500 000 population

depending on health need, geography and natural catchment); and

• meet required criteria and goals to receive ongoing Commonwealth

funding support.

Centre for Primary Health Care and Equity

PHC Strategy 2010

Building blocks:

• Regional Integration through

establishment of Medicare Locals

• Integrated information systems

(including PCeHR)

• Developing a skilled workforce

• Infrastructure including superclinics

• Financing and System performance

Objectives:

• Improving access, reducing inequity

• Better chronic condition management

• Increased focus on prevention

• Improving quality, safety, performance

and accountability

Centre for Primary Health Care and Equity

PHC Strategic Framework (approved by health

ministers 2013) • Medicare Locals, as partners of Local Hospital Networks, assist in

supporting and enabling better integrated and responsive local

primary health care services.

• As independent bodies, they will be working across boundaries in

primary health care and creating interfaces with the acute and aged

care sectors.

• Medicare Locals also have responsibility for:

• population health planning and needs assessment for their

regions,

• identifying gaps in primary health care services,

• and developing and implementing strategies,

in collaboration with communities, population groups and service

providers that address these service gaps.

Centre for Primary Health Care and Equity

International experience

• Primary care organisations have been established

(and disestablished) in the United Kingdom, New

Zealand and some provinces of Canada.

• Functions vary but they include improving access to

and quality of primary care and integration between

primary, hospital and social care (eg aged care).

• Evaluations have demonstrated some improvements

in access and quality but less evidence of integration

of care and continuing variation in performance

between primary care organisations.

Centre for Primary Health Care and Equity

New Zealand

Centre for Primary Health Care and Equity

Objectives of Medicare Locals

1. To improve the patient journey through developing

integrated and coordinated services

2. To provide support to clinicians and service providers to

improve patient care

3. To identify the health needs of local areas and develop

locally focused and responsive services

4. To facilitate the implementation of primary health care

initiatives and programs (including ATAPS, After-hours

access and Closing the gap in indigenous health)

5. To be efficient and accountable with strong governance

and effective management

Centre for Primary Health Care and Equity

Evolution

– 61 Medicare Locals evolving from the previous

Divisions network

– First wave of 19 Medicare Locals established

July 2011; 18 in January 2012 and 24 in July

2012.

– allocated flexible federal funding of more than

$1.8 billion over five years as well as additional

funding for specific programs such as Closing

the Gap, Access To Allied Psychological

Services (ATAPS) and After-hours care.

Centre for Primary Health Care and Equity

Role of Medicare Locals in planning and co-

ordinating primary care and community health

services

• undertake population health needs assessment and planning

(including joint planning with Local Health Networks and other

organisations),

• participate in the national performance and accountability

framework,

• analyse PHC service gaps including for disadvantaged or under-

serviced population groups

• identify strategies to improve health outcomes and quality of local

service delivery

• facilitate reduction in inappropriate service use and avoidable

hospitalisation.

Centre for Primary Health Care and Equity

Responsive programs and services to address

local community needs (AMLA)

• 2,600 community / consumer events, in planning and designing

services in response to local need;

• Over a million occasions of service provided by Medicare Locals

through a mix of direct delivery and commissioned services, often to

vulnerable and disadvantaged populations

• 445,000 mental health occasions of service including Access to

Allied Psychological Services (ATAPS), the Mental Health Nurse

Incentive Program, headspace and rural psychological services.

• 135,000 services through the Coordinated Care and Supplementary

Services Program to Aboriginal and Torres Strait Islander people

with chronic disease

• 350 new after-hours services to improve access to urgent after-

hours care, including contracting general practice, medical

deputising services, after-hours clinics and pharmacy

Centre for Primary Health Care and Equity

Actions to improve equity of access to health services

Effective strategies in increasing equity of access to PHC:

• Making primary health care more available

• Reducing cost to consumers (co-payers)

• Establishing systems to increase availability (appointments/afterhours)

• Involving non-medical staff in service delivery

• Developing culturally appropriate services and providers

• Increasing continuity of care, and providing reminders for follow up care

• Involving local communities, and responding to their needs

• Providing education to develop patient skills and health literacy

• Providing outreach services

• Offering support through telephone, or home visits

• Monitoring accessibility through audit and patient feedback

Shi L, Starfield B, Kennedy B, Kawachi, I. Income Inequality, Primary Care, and

Health Indicators. J of Family Practice, 1999; 48(4): 275-284

Centre for Primary Health Care and Equity

Actions by MLs to improve equity of access to health

services

Effective strategies in increasing equity of access to PHC:

• Making primary health care more available (workforce)

• Reducing cost to consumers (ATAPS)

• Establishing systems to increase availability (afterhours)

• Involving non-medical staff in service delivery (allied health)

• Developing culturally appropriate services and providers (refugee health)

• Increasing continuity of care, and providing reminders for follow up care

(hospital pathways)

• Involving local communities, and responding to their needs (community

consultation and engagement)

• Providing education to develop patient skills and health literacy (patient

education)

• Providing outreach services (Closing the gap)

• Offering support through telephone, or home visits

• Monitoring accessibility through audit and patient feedback (Practice

support)

Centre for Primary Health Care and Equity

Consumers Health Forum

• The Medicare Local Program has

already demonstrated its potential

to engage consumers as active

participants in their own healthcare

• While the performance of

Medicare Locals has been

variable, several have already

made significant progress in

identifying and assessing the

healthcare needs and gaps within

their communities.

• Medicare Locals have succeeded

in establishing and administering

existing programs including after-

hours care programs.

Australian Medical Association Web Survey of 1212 GPs

• 68.8% indicated that their Medicare Local

had failed to engage and listen to them about

the design of local health services.

• 60.8% believed that their Medicare Local

does not value or recognise the inputs of

local GPs.

• 61.9% indicated that their Medicare Local did

not have effective programs to provide

patients in aged care facilities with access to

allied health services in a timely fashion.

• 73.0% indicated that their Medicare Local

had not improved local access to care for

patients in comparison to the former Division

• 71.6% believed that their Medicare Local had

not improved the delivery of primary care

overall and should not be retained.

Diverse views on the performance of Medicare

Locals

Centre for Primary Health Care and Equity

Access to general practice

• The percentage of patients who had

seen a GP in the preceding 12

months, and who felt they waited

longer than acceptable to get a GP

appointment, ranged from 28% to

8% across Medicare Locals

• The number of after-hours GP visits

per person varied from 0.71 visits per

person to 0.03 in 2010–11, and from

0.79 visits to 0.05 in 2011–12. The

number ranged from 0.71 visits per

person to 0.14 visits across metro

Medicare Local populations

nationally in 2010–11 and from 0.79

visits to 0.15 visits in 2011–12.

Percentages of children aged 1 year fully immunised, by

Medicare Local catchment, 2011–12

The percentage of children aged

1 year fully immunised ranged

from:

Highest 94% – Great South

Coast (Vic), Hume (Vic),

Barwon (Vic), Murrumbidgee

(NSW), Grampians (Vic),

Goulburn Valley (Vic),

Australian Capital Territory

Lowest 85% – Far West NSW

The percentage of Aboriginal

and Torres Strait Islander

children aged 1 fully immunised

ranged from:

• Highest 94% – Gold Coast

(Qld)

• Lowest 69% – Bentley-

Armadale (WA)

Centre for Primary Health Care and Equity

What next: Medicare Locals review

Led by Prof John Horvath AO is examining

• the role of Medicare Locals and their performance against stated

objectives

• the performance of Medicare Locals in administering existing

programs, including after-hours GP services

• recognising general practice as the cornerstone of primary care in

the Medicare Locals functions and governance structures

• ensuring Commonwealth funding supports clinical services, rather

than administration

• processes for ensuring that existing clinical services are not

disrupted or discouraged by Medicare Local programs

• interaction between Medicare Locals and Local Hospital Networks

and other health services, including boundaries

• tendering and contracting arrangements other related matters

Centre for Primary Health Care and Equity

Questions? / Discussion

m.f.harris@unsw.edu.au

www.cphce.unsw.edu.au