As previously reported at Croakey, there have been mixed reactions to the Government’s change of plans regarding diabetes reform. Plans to introduce voluntary patient enrolment with block funding for general practices for enrolled patients have been deferred, pending the results of a coordinated care trial due to begin next July.
Professor Helen Keleher, president of the Public Health Association of Australia, says there may now be an opportunity to take a broader approach to improving care for people with diabetes.
Instead of entrenching GPs as the gatekeepers of care, perhaps more sweeping reforms should be considered – such as a trial of incentives for people with diabetes, she says. For example, people on low incomes with diabetes could be given vouchers to help them buy the insulin, equipment and fresh fruit and vegetables they can’t afford.
Helen Keleher writes:
Trials in the Australian context have merit of course, so that the costs, benefits and unforeseen issues can be identified before a major rollout of funding occurs.
The diabetes plan proposed makes the assumption that once enrolled, people with diabetes will have good access to the range of allied health and community based programs which are valuable in helping people become empowered to manage their condition.
Empowerment and steady social support from professionals who have the time to provide it (such as nurses and allied health) are the keys to chronic disease self management.
But there are many barriers to people successfully managing their diabetes and in Australia, we seem reluctant to address them.
No program to address diabetes management will succeed unless it takes into account people’s socio-economic circumstances.
Poverty is a leading risk factor for Type 2 diabetes. Conservative estimates are that 15-20% of Australia’s population is living in real poverty, and those groups are likely to have double-triple the rates of Type 2 diabetes that the rest of the population.
And with less than half the population having adequate literacy to function in today’s society, the pausing of the diabetes trial is an opportunity to develop a more rigorous and thorough approach to reforms of diabetes and primary care – how exciting it would be if the Minister announced that Australia’s approach to diabetes would be through a comprehensive primary health care approach!
We do know what a primary health care approach to diabetes management looks like but it is resisted because many of the components that contribute to a PHC approach are in the public sector.
This is evidenced by low rates of referral from general practice to community health programs (eg for nutrition education, smoking, physical activity) that also provide supportive environments at very low cost, especially for people on low incomes.
Appropriateness, accessibility and affordability are keys to access in a primary heath care approach.
GPs should not be set up as the gatekeepers between those programs and people’s access especially when people struggle to afford to see a GP in the first place. Enrolment of people with diabetes would be useful but the enrolment data needs to be accessible across the PHC sector as well as the primary care sector.
The people who really need incentives are the people who are struggling to manage their diabetes. For much less than the funding currently being advocated to incentivise general practice, how about a trial of incentives for people with diabetes?
A trial of vouchers to people on low incomes with diabetes to help them buy the insulin, equipment and fresh fruit and vegetables they can’t afford, and give them a reason to engage in physical activity and feel in control, would provide good evidence about what works for people, in what circumstances, at what cost and in a timely manner.
Now that would be health reform.
I’ve always though case managers for chronic health problems was a good thing for the government to do. If people are unable to manage their illness themselves (which people with diseases really need to do), it might be better to have someone else doing the organising. They could find GP’s that bulk bill, organise blood tests, make appointments with specialists such as dieticians and endocrinologists and perform weekly assessments of blood glucose levels etc. Diabetes educators could perform this role…there is no need for doctors to get involved (as is the case of GP’s), and would probably be a more cost effective solution. They could operate in small local areas and see multiple clients. Having a case manager might help those who feel they are powerless to navigate our complicated health system.