Tuesday, July 10, 2012

THE MEDICARE LOCAL AS ORCHESTRA!*


I want to try out an idea with you. 

Everyone I meet is struggling to say what a Medicare Local is and what it should do.  I would like to propose an analogy – that Medicare Locals are like large chamber orchestras – many instruments and an unobtrusive conductor who may be one of the principal players with special leadership skills.  

Many Divisions of General Practice operated well, bringing general practitioners together for fellowship, education and program development and into better working relations with community health and allied health professionals.  But with the advent of Local Hospital (or Health) Networks (or Districts), whose size makes good sense in terms of the skill mix that can be maintained to meet the health needs of the community and managerial effectiveness, we need an organisation in the community that more or less matches the networks in size.  One day, I prophesy, Medicare Locals and Hospital Networks will work together seamlessly and be funded from one source.  Not for now.

The music that Medicare Locals make occurs when the various players are in tune (no matter their instrument) and in time and they stick to a score.  You need many different players and instruments – one of this and half a dozen of that – to get the best results depending on the music.  Rehearsal is critical as is discipline and enjoyment from working well together.

OK – let’s run with the chamber orchestra idea for a bit. What music does it play? 

First let me tell you about a cold winter’s evening a couple of weeks ago when I had the privilege of meeting with about 50 local people in the Carrington Hotel in Katoomba (NOT what you’re thinking!) to talk with them and colleagues from the Nepean-Blue Mountains Medicare Local (ML) about the health needs of their community and how the ML might help to meet those needs.

Once we got over the hurdle of ‘what on earth is a ML?’ the conversation was wonderfully open, focussed, concerned.  I was especially impressed with how often people were thinking well beyond themselves and their own needs, and instead considering the community itself.  Several needs popped up from all over the room – linkage among care providers for patients with continuing and complex problems, mental health and transport. Let’s locate them in the Medicare Local.

Symphony in C Major?  It depends on better linkage among the care providers for people who access different health services.  Time and time again we heard about failed hook-up among providers of care for chronically ill older people.  Yes, yes, I know – when the day of the personal electronic record has fully come all many communication problems will be solved.  In the meantime, we should be thinking about a patient-controlled note book (pen and paper variety) into which the patient puts details of each consultation. 

Many general practitioners have formed informal email and telephone linkages with specialists and other carers and coordinate through those media.  Hospitals increasingly fax or email summaries to general practitioners after patients have been discharged, but more is needed. 

With the pen-and-paper book (and yes, a few will get lost or forgotten) health care professionals may be able to help with summaries that could be printed and stuck into the book, including meds and doses.  By whatever means, we need a common score to play from.

That way when, as one general practitioner put it, a patient with a complex chronic problem consults them, they will be able to go beyond just asking the patient what has been happening to them with other health care providers.

And vice versa – when patients turn up at hospitals at 2 am it would often be helpful to have more detailed accounts of what has been happening.

But you can imagine how much better this symphony would sound if everyone had the same musical score to play from. The RACGP Blue Book gives us a happy precedent: we need something similar for grown-ups.  The ML could help by first sussing out what communication networks exist and work well and where much more work is needed.

Concerto in D Minor?  That must surely be mental health. The Katoomba people perceived many different aspects of this broad-spectrum problem.  Disturbances of mental health come in all shapes, sizes and degrees of severity. We agreed that a blend of community and institutional care is needed and that opportunities for prevention, especially among young people, are frequently slipping through our fingers. How could the ML help?

A comprehensive ML should be in close touch with psychologists, general practitioners, community health, psychiatrists and the education authorities.  This is not impossible and if given real priority could work brilliantly.  All that was said about the need for far better communication among the players in chronic disease symphony can be said for mental health as well. There are so many commissions, reports, inquiries, and task forces that circle the planet like satellites at present that it is hard to know how to use them to best effect.  In the meantime we should focus on the local scene.

Then the third symphony where we need a strong conductor and players recruited from beyond the health arena is transport.  People at the Katoomba meeting meant transport of all forms.  Patients coming from Lithgow – hardly a distant country town – can catch a train to Sydney or Katoomba only once every two hours.  This may be fine if you’re fit but it can impose huge burdens on those who are unwell.  An appointment in Penrith, Westmead or Sydney runs late and you miss a train by five minutes – wait 1 hour and 55 minutes for the next one, with your arthritis, heart failure or COPD.  Tough luck.

Buses often follow routes that do not suit the chronically ill.  Years ago I worked with a bus company in western Sydney that changed its routes after consultation to better serve the needs of older citizens, so change is possible.  By default the ambulance service is pressed into service. 

An ML might seek to learn in detail what transport needs for health care its community has and then advocate with local government and state government departments to organise services better.  That’s a reasonable aim in a democracy.  We bang on about keeping patients with chronic illness out of hospital.  Well, by improving transport for them we may help achieve this goal.

The Medicare Local is not just another institution.  It is a way of organising community-minded health professionals and others interested in the health of the citizenry so that good music follows.  Because of its complexity and function it is a hard idea to get.  Medicare Locals need people to take music seriously – tune up, coordinate, cooperate, read the score (don’t guess), practice and enjoy.  After all the word orchestra literally means ‘a dancing place’ so feel free! 


*Previously published in AusDoc

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