DOCTORS REFORM SOCIETY

GP Superclinics Initiative – draft Program
Overview February 2008

DOCTORS REFORM SOCIETY

 

Megan Morris
First Assistant Secretary
Primary and Ambulatory Care Division                                                              

24 February 2008

Thank you for the opportunity to respond to GP Superclinics Initiative – draft Program Overview

We are strongly supportive of the principle of the establishment of integrated multidisciplinary clinics providing comprehensive primary care targeted initially to areas of greatest need.

We applaud the concept of infrastructure funding to enable the establishment of such clinics.

We are concerned however, that the proposed model does little to attract doctors and allied health staff to the areas of need, and more importantly it ignores many of the current barriers to integrated care in these areas of need and indeed reinforces some of those barriers.

1. Workforce: The attraction of new infrastructure and the chance to work with other health professionals will certainly lead to local health providers moving into such centres. These factors combined with the co-location costs will lead to some new providers moving to the centres. In a situation of nationwide workforce shortage however, these attractions are unlikely to be able to compete with the attractions of practice in other areas of less need, where providers can earn just as much or much more, working in conditions over which they may have much more control.

The very existence of these areas of need in which the clinics are to be established is significantly contributed to by the funding mechanism for primary care. Fee for service funding determines the distribution of all Medicare rebate funding and almost all PBS funding throughout Australia. That distribution is heavily skewed away from areas of need simply because doctors don’t work in such areas. The attractions of other areas include lifestyle, type of patient and type of work, and capacity to charge copayments. The capacity to charge copayments also means that in areas of lesser need spare funding is available for the types of things which are to be funded through this initiative. Thus, this initiative’s capacity to attract sufficient appropriate health providers to function is a serious concern.

We commend the provision of infrastructure spending on teaching facilities, as professional development is also crucial to the development of teamwork. The absence of any significant provision for recurrent funding however is a severe limitation on the usefulness of this provision

2. Integrated Care: The co-location of health professionals with some recurrent funding for administrative support is an excellent start to the development of integrated care. But built into the proposal are barriers to teamwork. Fee for service funding for individual practitioners reduces the likelihood of individual practitioners finding the time to work with others and share their skill and their opinions. Those of us who have worked in Aboriginal health services and community health centres are well aware that managing the complex needs of marginalised and disadvantaged people is more effectively handled by salaried GPs working as part of a multidisciplinary team.

In community health centres in Victoria, where one might naively hope that the patient is central, pressure has been applied directly to doctors to increase income either through increased throughput or increased use of other items which may or may not be appropriate or lead to any patient benefit, because throughput determines the budget, and the budget must be addressed. These pressures, whether from other staff or from the individual, are in direct conflict to the development of a team approach to patient care. .

Community health centres in Victoria already attempt to provide integrated multidisciplinary care. They can have up to 40 different funding schemes from Federal, State, and Local Government. Apart from the bureaucratic nightmare this presents to the organisation in terms of multiple accountability measures and funding applications, it is a further barrier to patient based care. One patient fits the criteria for a certain type of service, and needs a small amount and can easily get it. Another patient desperately needs the same service but doesn’t fit the criteria. The care given is not patient centred, it’s program centred, and this proposal does nothing to address the issue and thus cannot expect comprehensive patient centred care to be delivered in such clinics.

In addition, the different funding mechanisms for different health professionals is a further barrier to the development of a team approach to care.

3. Accessible and affordable care: the proposal indicates that bulk billing will be encouraged. These are areas of need. Are we to continue to rely on a doctor’s estimation of the worthiness of a patient’s need? We have a rebate system which actively encourages doctors to charge a copayment to adults in working families because the rebate for such adults is lower than the rebate for health care card holders, pensioners, and children. Why not simply require that these clinics bulk bill everyone? How will the assessors monitoring adherence to the Program Objectives know whether 5 or even 20% of patients have not attended or delayed their attendance because of cost?

4. Responsive to local community needs and priorities: There is so little detail on governance and the involvement of the local community that we are concerned that such involvement could be quite superficial in the face of the much more powerful stakeholders who must be involved.

Program Objectives: General comment. Whilst flexibility to suit local needs is appropriate, the program objectives as stated are so loose that it’s hard to know what will really be expected. With no recurrent funding to improve the gross inequities of recurrent funding through Medicare and the PBS to these areas, the likelihood that Superclinics will significantly address the health outcome inequalities in these areas is low. Without measures other than co-location to foster teamwork, significant improvements across the country in these areas of need are unlikely to occur.

We strongly support the concept of integrated multidisciplinary primary care clinics, initially sited in areas of need, but expanding to other areas with time. For such clinics to function optimally to deliver integrated care to the most needy in our community requires

• A different recurrent funding model than simple reliance on the predominantly fee for service model which exists
• Integration of the multiple funding streams.
• Salaried service as a key feature to form a structural basis for the development of a team approach to care.
• Bulk billing or no copayments to ensure no financial barriers to access
• Significant community input at governance level.

Requirements of such clinics need not be overly prescriptive; the local community needs and the capacity of the health professionals to address those needs can determine much about how such clinics run and what the mix of professionals should be. Properly funded clinics of this nature would be a perfect site for an expansion of the role of nurse practitioners.

We would be delighted to discuss these issues further

Dr Tim Woodruff, President, Doctors Reform Society