Opinion & Commentary
Will Super Clinics increase the pressure on public hospitals?
In the 2008–09 federal budget, the Rudd government allocated $275 million to the establishment of a national network of (an initial) thirty-one GP Super Clinics.
Super Clinics will be multidisciplinary primary care centres bringing previously dispersed general practitioners, practice nurses, and other allied health workers together under one roof.
Pursuing this policy will involve a significant expansion of Medicare beyond traditional fee-for-service GP primary care. Super Clinics will expand Medicare-funded access to a range of ‘wellness’-promoting services—from dieticians to physiotherapists and psychologists—which, despite recent initiatives, Medicare has so far provided only limited access to.
The government maintains that the aim of its Super Clinics policy is to develop new models of ‘preventive health services.’ To boost the secondary prevention of chronic disease, Super Clinics will be designed to provide patients with established chronic disease (especially elderly patients) with enhanced access to ‘coordinated’ primary care.
Coordinated primary care (which is sometimes referred to as ‘managed care’ or ‘disease management’) involves a GP or a practice nurse monitoring the condition and managing the care of chronically ill patients to ensure they receive all available care from a wide variety of allied health providers. Coordinated care also involves better educating patients about their disease so they can better self-manage their condition and maintain their health, with particular regard to the secondary prevention of lifestyle related comorbidities (an additional one or more chronic conditions—diabetes, for instance, can lead to heart disease and stroke), which can cause complications and more frequent, longer, costlier hospital stays.
According to the proponents of GP Super Clinics, coordinating the care of chronically ill patients with complex needs—who are expected to overwhelm the public hospital system as the population ages into the middle of the twenty-first century—will produce better health outcomes at a lower cost. The attractive idea is that coordinated care will prevent chronic conditions from deteriorating, and so will prevent patients from requiring higher-cost secondary care and emergency department and inpatient services.
The theory is that if the primary care received by the chronically ill is coordinated, they will supposedly not need referral to secondary specialist and hospital-based tertiary care, and their condition will be less likely to deteriorate to the point they require urgent, unplanned, and ‘avoidable’ admission into hospitals. Champions of investing in coordinated care therefore suggest that while it is more expensive than traditional primary care, the cost will be offset by the savings achieved by substituting cheaper primary care for more expensive treatments, and by reducing the utilisation of higher-cost hospital-centred services.
The Rudd Government therefore maintains that its investment in coordinated primary care represents a cost saving and hospital demand management measure, since Super Clinics will, in the words of the health minister, Nicola Roxon, ‘keep people in good health and take pressure off public hospitals.’
The problem with this claim is that a considerable body of evidence strongly suggests that coordinated primary care will not reduce utilisation of hospital services, as is often predicted. Instead, what the results of various coordinated care programs in Australia and overseas appear to have demonstrated is that lack of coordination acts as a ‘rationing’ device. The evidence strongly suggests that improving the access chronically ill patients have to coordinated primary care tends to uncover unmet needs and new cases requiring hospital-based treatment.
What this suggests is that we must think about Super Clinics in terms of their real impact, in the first place, on primary care. If the government can find the doctors to staff them, Super Clinics will put more primary care resources on the ground, especially if they are located, as announced, in low-income areas suffering GP shortages.
Because the current primary care system is of relatively low quality, Super Clinics offering coordinated care will almost certainly improve the quantity and quality of primary care offered. The likely result is that Super Clinics will enable more chronically ill Australians to secure all available beneficial care. Better ensuring primary care can fulfil its traditional role of timely detection and appropriate referral to necessary treatment would undoubtedly be a good thing for patients. Given all this, it would be strange to argue the government should not proceed with the Super Clinics policy.
The point is, however, that the impact and implications this will have has not at all been acknowledged in the broader policy discussion surrounding Super Clinics. Rather than alleviating the pressure on public hospitals by ‘keeping patients well and out of hospital,’ the evidence suggests that GP Super Clinics are highly likely to add to the pressure on public hospitals.
Dr Jeremy Sammut is a researcher at the Centre for Independent Studies. His paper, ‘The False Promise of GP Super Clinics Part 2: Coordinated Care’ was released today.
