Though it has the potential to increase objectivity, improve targeted delivery of services and reduce conflicts of interest, opening primary care to market forces is a poor fit for the Australian context and stands to entrench disadvantage, according to a new study published this week.
Authored by Julie Henderson and colleagues from Flinders University’s Southgate Institute for Health, Society and Equity and published in the latest edition of Health and Social Care in the Community, the study examines a role for commissioning in addressing equity, drawing on 55 stakeholder interviews across 6 Primary Health Networks.
— Fran Baum (@baumfran) June 13, 2017
While benefits were perceived by interviewees — a group comprising 23 senior PHN staff, 11 board members and 21 community advisory representatives — several barriers to equity were identified with the commissioning model:
- Funding: shortages and linkage of funding to specific initiatives (‘same old types of services’, especially in areas such as mental health) limiting flexibility and innovation
- Aboriginal communities: structural incompatibility with the highly successful ACCHO model including unrealistic time pressures; contribution to clinician turnover and erosion of trust/relationships; forcing ACCHOs to compete with other providers for service provision and loss or reduction of Aboriginal Health Worker positions and local expertise
- Rural and remote: access to relevant, appropriate services to commission in rural and remote areas; potential loss of local expertise and employment opportunities to big business; and conflicts of interest where commissioning groups were also service providers in these areas
- Dynamics: shifting emphasis away from collaboration towards competition and undermining existing relationships, purely on a financial cost-benefit analysis which does not take intangibles (local knowledge, trust) into account; increasing workload and pressures on clinicians
Of particular note, the authors said commissioning by its nature tended to disadvantage populations most in need of service provision. In the Australian context, Indigenous communities were seen as most likely to suffer, with economies of scale difficult to achieve but care needs most acute.
This paper has reviewed the views of key stakeholders in PHNs ofthe impact of commissioning on achievement of equity of access.Respondents identified a number of political, population and geo-graphical features of the Australian context which make achievementof equity through commissioning more difficult.Among these are the impact of a Federal system in which secondary and tertiary health services are provided by State and Territory government; funding and service models that work against the interests of ACCHOs; and regions with limited access to services to be commissioned.All suggest that a market model may not be the best option for primary healthcare in Australia.
Advocacy and access
These findings tie in nicely with a paper just released by the Wellesley Institute in Canada looking at the role of Community Health Centres in advancing health equity, based on interviews with CHC CEOs and executive directors.
Through improving access to health and addressing social determinants such as housing, income, employment, food security, transport, early childhood development, education and discrimination, CHCs were seen as having a critical role in improving equity. Of importance, advocacy was seen as an “essential and integrated” element of their mandate, both at individual/organisational and municipal/provincial/federal policy levels.
— Wellesley Institute (@wellesleyWI) June 12, 2017
Some of the ways CHCs worked to reduce barriers to access included:
- appointment of peer workers to improve outreach and delivery while growing skills, knowledge and networks of clients
- multi-service funding arrangements and partnerships to secure additional services for clients such as community gardens, eviction prevenetion, supervised injecting sites and legal clinics
- training and mentorship for staff to improve service delivery to trans clients or those with a disability
- successful lobbying on budget cuts (especially on refugee health), bike lanes, extension of health insurance to babies born to parents without citizenship status, sexual education reform, minimum wage increases and expansion of national prescription drug coverage
- involvement in resident-led campaigns and initiatives on tenancy, poverty, racism and provision of spaces, child care, admin support and capacity-building in support of these services
CHCs are funded in a similar fashion to Australia’s PHNs and CEOs/EDs said there was a tension between the core work of service provision and their advocacy work. Being paid for and evaluated on service provision meant strategic decisions had to be made on where to best spend scant resources for advocacy, focusing on where gains were most likely to be made.
This was seen as a barrier to increasing equity and access, with one director describing the “great dignity of resistance”.
One of the successes of advocacy is keeping that zeal alive, that change is possible, that things can be different, that we need not resign ourselves to live forever with these sets of inequalities and that for me is quite powerful as a success […] that for me is quite powerful from the perspective of folks who experience inequality seeing, maintaining kind of the dignity of resistance.Because there’s a great dignity of resistance because it says that we will not settle with inequality forever.If you can improve the lives of your patients, that’s basically it. If you can improve the life of your patient and can improve the resilience of your patients while also the resilience of your community and vitality of your community and keep it willing to move forward is very important.One of the things that I know is that if pain doesn’t move, it will crush you. So if there’s nowhere for our staff to take the pain of what they see and the injustice of what they see and to move it, then you know there’s a high risk of implosion. If the community sees no way to take their pain, the injustices that they’re experiencing and move those, then they’re going to be crushed.