Stephen Leeder: Fiddling with health

A YOUNG executive is starting a new management role. Her predecessor bids her farewell, saying: “Here are three envelopes to be opened one at a time when things are really grim. Goodbye and good luck.”

After 6 months, sales began to fall and the new executive opens the first envelope. It says: “Blame your predecessor”. She convenes a staff meeting and explains how the current crisis is due to faulty policies pursued by the man she’d replaced.

It is a powerful statement that also works in politics, where no explanation for a mess or budget deficit begins without the spokesperson reciting these words.

A year later, a further crisis leads our executive to open the second envelope. It says: “Restructure”.

So she amalgamates units and divides others; renames a department here, and outsources another there. Things pick up but the expense of the restructure is huge.

The third envelope, opened a few months later because the restructure is faltering, reads: “Prepare three envelopes”.

Restructuring is common in health as governments come and go. Yet health service researchers have shown it is mostly expensive and achieves remarkably little for patients or those working in the system.

Why can so few governments resist the temptation?

With this in mind, a high level of scepticism is appropriate when assessing the upcoming move from Medicare Locals (MLs) to Primary Health Networks (PHNs). Health Minister Sussan Ley says that the change signals a move from backroom bureaucracy to improving front-line services. Really?

The MLs were criticised for marginalising GPs and getting into service provision, so the PHNs are not supposed to provide any services directly.

However, there is already confusion over the role of private health insurers — are they in or are they out — which is similar to that which surrounds the role of our military trainers in Iraq. Do they have a combat role? We cannot be sure in either case.

Initial assessments indicate the similarities between PHNs and MLs are more striking than the differences.

Some functions for the new PHNs that stand out are ones that have shown their worth in MLs.

The PHN can serve as a rallying point for GPs. This may sound soft and unimportant but the relative isolation of GPs, despite the flourishing of group practices, means they have good reason to band together for education, advocacy and fellowship.

If the PHNs can provide the context for GPs to achieve those purposes together, they will be highly valued.

Also, the PHNs can support efforts made through general practice and hospital specialties to provide joint care for patients who have serious and continuing problems, frequently multiple comorbidities. It means patients’ lives are not impaired by inadequate follow-up and a lack of medical care facilities where the patients are known and understood.

This has the potential to lead to less frequent admissions to hospital for such patients, although there are no guarantees.

Our own research into the care of such patients in Western Sydney leaves me with the view that often more — not fewer — services are needed for such patients, especially in allied health, nursing and other home support.

The extent to which PHNs can achieve these goals will depend in no small part on their internal workings, how they are managed and the contribution made by GPs.

For a federal government committed to reducing red tape, general practice is a good place to start.

Many of the MLs were saddled with ludicrous reporting requirements and endless bureaucratic fiddling.

If the PHNs can be liberated from this nonsense and set free to do their important work in the community, we will have a restructure in health that is worthwhile.

Professor Stephen Leeder is the editor-in-chief of the MJA and emeritus professor of public health and community medicine at the University of Sydney. Find him on Twitter: @stephenleeder

Jane McCredie is on leave.