|Implemented in this survey?|
In the lead up to the 2007 Federal election the then opposition party announced that it would support the establishment of so called "GP super clinics". The aims of these clinics are to firstly encourage general practitioners (GPs) to practice in parts of Australia where there are identified shortages. Secondly, the super clinics aim to deliver more services to the community including allied health services and place a stronger focus on preventive health services and chronic disease management.
The GP Super Clinics are intended to make health care more accessible by providing local health services together in one place - particularly in areas that are currently underserviced by health professionals. The clinics aim to attract doctors, specialist and health professionals to communities where they are needed most. The clinics will also aim to improve chronic disease prevention and management that require multidisciplinary care.
The GP Super Clinics, alongside other policy initiatives, are intended to:
Total funding available for the GP Super Clinics is AUD220 million. The initiative imbeds a raft of incentives including:
Importantly, the initiatives will not alter fee-for-service arrangements under existing Medicare arrangements. However policy documents state that strong preference will be given to GP Super Clinics tenders that commit to charge patients zero out-of-pocket costs.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Historically there has been a divide between various primary care providers. Under the previous government, this divide was slowly being eroded by broadening the types of providers eligible for Medicare subsidies. Under the Super Clinics initiative the government will provide infrastructure support to facilitate multidisciplinary care and reduce artificial divisions between federal and state funded primary care services. The Super Clinics were an important part of the health commitments made by the Labor Party in the lead up to the 2007 election. As such, the policy was developed to ensure minimum confrontation with stakeholders. Following the election, the Department has produced a draft program overview of the Super Clinic policy and has invited stakeholders to comment on this. The draft program does not appear to be publicly available on the internet*. However some submissions have been made public, including one prepared by the Australian Medical Association (AMA). The AMA is generally supportive of the objectives of Super Clinics but warns that existing GP services must not be undermined or made non-viable by the introduction of a Super Clinic.
*Since writing this survey, the Department of Health and Ageing has updated its website, providing more details of the program. This information can be accessed at www.health.gov.au/gpsuperclinics.
The Medicare program provides Australians with access to publicly subsidised primary care services usually provided by GPs. GPs are most often private providers paid on a fee-for-service basis. For approximately 75% of services, the public subsidy provided by Medicare is sufficient to cover the fee charged by GPs. For the remaining 30% the fee is higher than the subsidy and patients face an out-of-pocket charge equal to the gap between the fee and the subsidy. Whilst Medicare entitlements are universal, there are well identified variations within Australia in the degree of access to health services.
Typically, patients in rural and remote areas as well as in some outer metropolitan areas face greater barriers to access than their inner city counterparts, usually measured in terms of higher out-of-pocket costs but patients may also have travel longer distances and wait longer for appointments. There is widespread mal-distribution of the medical workforce in Australia that has contributed to this situation. Secondly, it is said that the fee-for-service system of the Australian GP sector has created incentives for doctors to provide short consultations and disincentives to manage patients with more complex needs that require longer consultations. Whilst there may be some truth to this assertion, there is little empirical evidence to support this claim.
In August 2007, the Labor Party in opposition launched its GP Super Clinic policy which formed a major plank of its 2007 election platform. Subsequently, 20 separate announcements were made outlining where the Super Clinics would be located. The chosen regions were said to have been seleceted on the basis of identified access problems and/or high health needs. It was perhaps a happy coincidence that of the twenty localities sixteen were located in regions where the Labor Party hoped to make significant electoral gains. The November 24 election resulted in a change in government with the Labor Party regaining office after 11 years in opposition.
|Implemented in this survey?|
The Australian Health Care System has often been accused of being fragmented with two layers of government (federal and state) sharing responsibilities. This has often led to an artificial demarcation between service providers (depending on whether they were paid by federal or state governments) and has also allowed politicians to shift blame for any inadequacies from one layer of government to another.
In terms of primary care, GPs are funded by Federal Government programs whereas community services are typically provided by state and sometimes local governments. Community services consist primarily of salaried allied health professionals that may include some community nursing services, counselling and child check-ups. Whilst GP and community services all provide primary care services to local communities there is very little evidence that these two sectors work together to provide an integrated service. At the same time, several state governments have started to examine how GP services and community services can be integrated through various pilot programs. The GP Super Clinics are based on these programs but with a greater focus on private practice GPs.
The approach of the idea is described as:
The then opposition Labor Party received relatively strong support from most stakeholders following the release of the GP Super Clinics Policy.
The then Minister for Health, Tony Abbott, criticized the policy on the basis that unless the clinics increase the number of doctors access to health services would not be improved. And if they do bring in extra doctors, they would be deliver 'unfair' government-funded competition for private doctors. The alternative approach, as implemented by the previous Government has been to slowly expand the range of privately provided services subsidized by Medicare. Medicare expanded to fund a range of nurse consultations including for vaccinations, wound management, pap smears and chronic disease, as well as psychologist consultations (Abbott 2007).
The Labor party used the policy to maximum political effect by identifying areas for the location of super clinics in the weeks prior to the election. The vast majority of those areas were in electorates where the Labor Party thought it might have a chance of winning the seat from current government members. Certainly the policy did them no electoral harm because Labor was able to oust 13 of the 16 government members in electorates where Super Clinics were to be established.
State governments (all Labor) were supportive of the super clinic policy and it became part of the political mantra that a Federal Labor Government would reform state-federal relations.
The Australian Medical Association stated that while GP Super Clinics were not the AMA's preferred model during the 2007 election campaign, the AMA has attempted to respond to the Government's proposal in a constructive manner. AMA input has focused on the quality and access of primary care services, the location of clinics, the management and workforce implications.
Recently, the Centre for Independent Studies, a think tank that aims to promote individual liberty and choice has published a monograph critical of GP Super Clinics. However, the paper's criticism seems primarily directed at the lack of evidence of a range of preventative interventions - delivered through primary care or other means - not at GP Super Clinics per se (Sammutt, 2008). Having said this, the monograph's author has foreshadowed a future publication that will reveal an alternative proposal.
|State Governments||very supportive||strongly opposed|
|Providers||very supportive||strongly opposed|
|Labor party (then opposition)||very supportive||strongly opposed|
None. This policy will not require legislative amendments.
|State Governments||very strong||none|
|Labor party (then opposition)||very strong||none|
The details of the policy are currently being negotiated amongst federal and state health ministers.
The first step towards implementation (yet to be taken) is to initiate a tender process within identified GP Super Clinic areas. Tenderes may include local councils, existing GP practices looking to amalgamate, other health profesionals and regional Divisions of General Practice.
No process for monitoring or evaluating the impact of GP super clinics has been announced although it will be feasible to evaluate the impact of clinics on GP access and utilisation using administrative data.
It will be harder to measure patient health outcomes and service use outside those subsidised by the Medicare program (e.g. community services) or its impact on reducing pressure on hospital emergency departments.
No evaluation conducted or foreshadowed.
There is little doubt that some parts of Australia are underserved by GPs and that this has resulted in higher barriers to access in some regions. The previous federal government enacted a number of initiatives to overcome this maldistribution but most of these have been unable to shift current worforce distributions.
The GP Super Clinics may offer a more supportive and cohesive working environment and attract GPs to underserved areas. To this extent, this policy may address some fundamental inequities in the Australian Health Care System.
The new Labour government also claims that this policy will help shift the primary care from short consultations to more comprehensive care focusing on chronic care and prevention. Whilst the multidisciplinary nature of GP Super Clinics may broaden the range of primary care services available to patients, the open ended fee-for-service nature of Medicare funding will still create incentives to supply GP services over other types of services that are funded on a salaried or capped basis.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Whilst it is difficult to substantiate claims of a fragmented and uncoordinated health care system, there is probably some truth to them. If the claims are true then the system is producing sub-optimal health care outcomes as well as creating inefficiencies. The GP Super Clinics are an attempt at improving care coordination by bringing together a number of primary care professionals under one organisational structure. This idea has merit but its success will be determined by how the clinics eventually operate. There is a risk that the inherent incentives of the Medicare funding system will be too strong to overcome this fragmentation.
Abbott, Tony (2007). Speech to Australian Health Insurance Association. Health policies 2007: a record versus a wish-list. Tuesday, 9 October 2007.
AMA (2008). Comments on the Draft GP Super Clinics Program Overview. www.ama.com.au/web.nsf/doc/WEEN-7DQ4UG/$file/GP_Super_Clinics_Initiative.pdf.
Australian Labor Party. New Directions for Australia's Health: Delivering GP Super Clinics to local communities. Available at: www.alp.org.au/download/new_directions_for_australias_health_gp_super_clinics_final.pdf.
Australian Medical Association. GP Super Clinic Submission. Available at: www.ama.com.au/web.nsf/doc/WEEN-7DQ4R6.
Sammutt, J (2008). The False Promise of GP Super Clinics, Part 1: Preventive Care. Centre for Independent Studies Policy Monograph 84. www.cis.org.au/policy_monographs/pm84.pdf.
van Gool, Kees