Governments around the world are under considerable pressure to ‘fix’ the health care system so that they can meet the increased economic demands being placed upon them as a result of an increasing incidence and prevalence of chronic disease. The Australian Federal Government's response to the economic forecasts in relation to health has been to introduce new mechanisms to improve allocative efficiency within the health care system. We have seen the introduction of mandatory partnering across sectors and the establishment of new primary health care organisations with greater emphasis on health promotion and disease prevention. Although these moves are celebrated by some, others approach such developments with more caution. On the positive side, this shift in the curve of health spending toward prevention is welcomed. However, this thinking is based on the assumption that prevention is cheaper than cure but, as some have argued, the validity depends largely on who is doing the preventing.1–3
Partnership approaches provide governments means through which to ‘influence the market,’ to improve allocative efficiency whilst simultaneously providing opportunities to re-introduce more radical approaches to health and into Australia's health care system. Blueprints exist for how health partnerships might operate effectively, yet the actual ‘workability’ of partnerships and their ability to improve health outcomes remains equivocal. Some researchers have argued that lack of evidence to support the partnership approach may be due to a lack of objective, independent measures and poor measurement. Others have argued that methodological issues arise from the action orientation and the sheer complexities of evaluating multiple interventions across multiple sites. Building evidence is certainly made more difficult by the fact that various strategies interact when delivered by different components of community-based health promoting partnerships and may interact to produce unexpected outcomes.
The future of health partnerships is made more challenging by the vicissitudes of government and resistance from providers of primary and secondary care. Even as this paper was being drafted the health reforms were being redrafted, resulting in new agreements being made between State and Federal Governments. Some commentators have complained that governments expect too much of community-based health promoting partnerships, particularly given the complex environment in which they operate.1,2,4–7 However, they may still offer some hope in terms of their ability to re-orientate health care toward prevention.
The divisions of general practice and general practitioners have been placed at the forefront of a renewed preventative agenda in Australia by conflating them into what was previously known as ‘primary health care’. Medicare Locals are a national network of primary health care organisations. These organisations will be regionally based, independent legal entities (not government bodies) accountable to the Australian Government, and will be expected to be responsive to local needs. They will be required to operate with strong local governance, have strong clinical leadership and work closely with Local Hospital Networks to improve patient care, quality of health services and improve the patient journey and transition between care settings.8 Placing the Medicare Locals at the forefront of this new preventative agenda may lead to the subjugation of traditional, more radical primary health care approaches which have a broader focus on the social causes of illness (i.e. the social determinants of health). Despite numerous reforms to health care, there is a constant move back toward more conservative models of prevention focused on risk behaviours at the expense of more fundamental factors.
That general practices are the best value solution to the prevention of chronic disease is questionable. Moreover, the idea that general practice should be at the forefront of preventative approaches to chronic disease is often legitimated on the basis that general practitioners are the most frequently visited health provider of primary services. However, this status is an artifact of the heavily subsidised fees, which make general practice a relatively cheap service, particularly for people of low socioeconomic status (SES). Further, as general practitioners have been established as the gateway to most other services, there are few other alternatives. Many general practitioners already complain of being too busy and in some areas there are too few supporting professionals, such as practice nurses, to help provide the tertiary or secondary level care needed. Finally, clinic-based models of care that are characteristic of general practice are sometimes inaccessible to the more disadvantaged groups within the community, diminishing the preventative impact of general practice even further.
Policy writers acknowledge that some aspects of health promotion are well beyond the scope of most general practices and recommend inter-sectoral approaches (i.e. partnerships) to help strengthen the preventative measures provided by them. However, something seems to have been lost in translation between the drafting of the reform documents in 2009, and the Medicare Locals discussion paper that appeared a year later. Although the reform documents focused on partnerships and broad determinants of health, the ‘Medicare Locals: Discussion paper on governance and functions’, released in 2010, only mentioned partnerships once and the social determinants of health were not mentioned at all.8
The Medicare Locals discussion paper stands alone in comparison to other recent key health policy documents distributed globally and within Australia, all of which emphasise the importance of partnership approaches and the social determinants of health.1,3,4,9,10 One can only hope that the new Medicare Locals reconfigure their final designs to align more closely with those of international and national health policy documents. Importantly, Medicare Locals will have to enter willingly into partnerships if they are to fulfil their new mandate to improve health outcomes in relation to chronic disease.