Thursday, September 11, 2014

ASSESSING VALUE BEFORE DEMOLISHING

In the current confusion in health that has followed from a swath of defunding, abolitions, co-payments and diminished Commonwealth funding, it is easy to lose sight of the needs of the individual patient. 

Typically and increasingly, the people who need our health care have a combination of problems such as diabetes and heart disease requiring concerted attention from hospitals, community nurses, general practitioners and community-based specialists. We do not have the firm evidence to say how best to do this, and hence in NSW the state minister for health, Jillian Skinner, has allocated $130m over 3 years to test out alternate ways of achieving this end.  Recently Medibank Private and other private insurers have expressed interest in testing strategies using community nurses to achieve the best alignment of care for our typical patient.

One of the casualties of the federal slashing has been what was called a Medicare Local, an organisation established by the previous government to create an environment of support for general practitioners and the long-term care of patients with chronic problems.  Their function was patchy, as expected from new entities, but where they worked they worked well. But the decision was taken recently to scrap all 61 and start again, with different, fewer entities called primary health networks.  Demolition and rebuilding is an expensive hobby.

In NSW, where we have 17 hospital districts or networks, there were 16 Medicare Locals.  While the match was imperfect, you get the drift.  In places such as western Sydney, fortune favoured us and the Medicare Local and the hospital district covered the same geographic area – from Mt Druitt to the Hills to Parramatta and Auburn.  Good things followed in coordinating care and hospitals and community practitioners learning to work together – for the good of the patient.

The document that evaluates the Medicare Locals concedes the value of a one-on-one relationship but envisions larger organisations combining the roles of smaller Medicare Locals.  What a pity. We know from past experience that the size of the NSW health districts is just about optimal – make them bigger and they are a managerial nightmare; make them smaller and you lose economy of scale.  Each has a degree of local identity and that identity is reflected in the Medicare Locals that serve the community especially when the overlap is complete.

If the federal minister wishes to experiment with how to meet the needs of the patient with chronic problems, why not leave NSW as it is and try out different models in other states such as Victoria that has no fewer than 90 hospital networks.  Or Queensland.  He has encouraged private insurers to experiment so why not his own ministry? 


Tearing up the crop before it has had a chance to bear fruit is expensive and wasteful.  Even more so with Medicare Locals.  Of course many of them can benefit from more energetic and focussed management, but there is no monopoly on that.  Let the plants grow.  We’ll find out soon enough whether the NSW model – one Medicare Local per hospital network – is the best way to go or whether we have been trumped by the Victorians again. 

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