One of the points of (possibly minor) differentiation between Labor and the Coalition in this election campaign is the two parties’ positions in relation to GP Super Clinics. My suspicion is that Labor is rather partial to the title, Super Clinics; it’s rather P.G. Wodehouse, super and all that. Who is in their right mind is not in favour of super? SUPER!
When it comes to GP Super Clinics, quite a few are not in favour of them, including the AMA and other groups representing doctors. Perhaps one bit of good news – although I guess it is a broken promise - is that compared with the 2007 election commitment made by the ALP, the number of GP Super Clinics that have been built and are now in operation is low.
This issue of the economic rationale for GP Super Clinics is discussed by health economist, Professor Jim Butler, in an excellent article in the Winter edition of Policy, from CIS (subscription required). Butler queries the rationale for government subsidy of these GP Super Clinics in the context of what is essentially a free market for GP services, subject of course to the high degree of government subvention in this market as a result of the MBS (but which apply to all registered GPs on a like basis).
“Not only does the GP Super Clinics program fail to corrent a market failure but there is a possibility that it will end up underwriting business failures”, according to Butler.
Butler also raises the important issue of whether the GP Super Clinic program introduces an element of unfair competition for existing GP practices – it is interesting to ponder whether there is a violation of competitive neutrality as only these GP Super Clinics obtain capital grants and are not available to other GPs.
Should existing GP practices be driven out of business – and there seems a reasonable likelihood in some instances – will consumers of health services be worse off? Certainly in terms of distance travelled, the replacement of many small GP clinics with a much smaller number of GP Super Clinics will inevitably mean that the average distance travelled by consumers of health services – call me old-fashioned, but I prefer the word patients. And then there is the loss of continuity of care from a GP if his/her practice closes down.
The idea of a one-stop shop will in all likelihood turn out to be a folly in practice. While various health professionals may be housed within the same building, the probability of patients being seen on the same day in some seamless arrangement is very low, given the excess demand on the services of most specialists, dentists and psychologists.
If there is a choice between more GP Super Clinics and more money to be spent on mental health – and please note, that GPs play a very peripheral role in mental health – I know where the emphasis should be. And not just additional mental health services for young people, but for people of all ages who are affected by mental health conditions.
Missing words: the average distance travelled by patients would inevitably increase.
To be replaced with myClinic, myHosptical, myJoint Strike Fighter, myInterstate Commission, blah blah blah
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18 Jul 10 at 1:15 pm
“and please note, that GPs play a very peripheral role in mental health”
You might want to consider the actual data here before saying that (especially the data on the recent blow-out in the governments mental health budget if you can get it — I can’t find a link right now). GPs may well be quite peripheral in terms of what they do, but not peripheral in terms of taking money from the government mental health pot. If you look at where the money from the most recent pot went, you’ll find that GPs, who do next to nothing apart from direct people somewhere else, are a major group abusing it and and causing the blow-out (since they get a cut for referals). The other problem with providing all this money even to psychologists is that the people using it are not necessarily always the ones you want — the best services are now in rich neighborhoods where people could afford it anyway, just like doctors (which is not say they arn’t needed there incidentally — in Victoria, for example, I believe the highest rate of alcoholism in females is in Boroondara — think, bored housewives with rich husbands and rich bored retirees), and the take-up of services with people you really might like to get them for free (e.g., males living in poorer suburbs) has been poor, both for cultural reasons but also because there simply arn’t services in areas for them (there are also problems with training people that can actually deal with these groups and that these groups are willing to deal with — at a guess, 70% of psychologists are middle-class white females). So your second statement is really on the money, except the problem isn’t providing too many services for young people in a comparative sense, it’s with providing free services to other groups that already have money.
conrad
18 Jul 10 at 2:20 pm
The idea of a one-stop shop will in all likelihood turn out to be a folly in practice.
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Yes.
As Conrad pointed out on your post yesterday, the way forward is to have a diversified, specialised health system, not create this bloated mini-bureaucracies in every town.
daddy dave
18 Jul 10 at 3:56 pm
“and please note, that GPs play a very peripheral role in mental health”
I don’t believe that is true. GPs are the first point of contact and the point of diagnosis for most mental illness and prescribe most of the medication. Relatively few patients see a psychiatrist.
“(since they get a cut for referrals).”
GPs get a fee for the consultation producing a referral but there is no kick-back or commission from the specialist fee.
I do agree on the nonsense of super clinics. As you day JS it is just about impossible to match the supply and demand for all.
ken n
18 Jul 10 at 4:02 pm
at a guess, 70% of psychologists are middle-class white females)
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It’s undoubtedly higher than that, but that’s not a problem in itself. After all, many other health and welfare groups such as doctors and dentists tend to be relatively homogenous.
If they could be motivated to work with lower class and ethnic groups, with the right training I’m sure they’d be fine.
There’s no supply-demand incentive.
The motivation just isn’t there when they can rake in medicare, just from sitting in a nice leafy suburb a short stroll away from a coffee shop and bakery, counselling middle-class people about their unexplained angst.
daddy dave
18 Jul 10 at 4:04 pm
by the way Ken… that previous comment of mine wasn’t meant to be diminishing the reality of depression. I was giving a colorful illustration of the disparity between where psychologists want to work (and where they are able to thanks to generous government subsidies) versus working where there is greatest need for their services.
daddy dave
18 Jul 10 at 4:09 pm
I think you are underestimating some psychologists,dd, who do go where they are needed and the Medicare benefit did encourage that, a bit.
Still your point is broadly accurate.
Though studies say CBT and such are effective for mild to moderate depression, I’d like to see some evaluation of the additional work done by psychologists since they got access to Medicare.
My guess (fear) is that the effect has been slight.
CBT is hard work for the patient – not everyone is suitable and even fewer stick it out.
ken n
18 Jul 10 at 4:52 pm
“GPs get a fee for the consultation producing a referral but there is no kick-back or commission from the specialist fee”
Actually Ken, what you’ll find is that GPs are supposed to be doing a whole range of things to get the fees they get for mental health stuff, and indeed they get a special set of rebates for doing this (e.g., developing a treatment plan and so on, all of which takes a lot of time see e.g., here). At present, a lot are taking the money and not actually doing all things they are supposed to for this. So typically they take the money and shunt the problem off to someone else, who also gets paid from the government and is happy to get the work.
One of the big effects of this is that they are taking a decidedly large slice of the mental health pie — so much so that the amount budgeted has vastly exceeded what the government initially wanted to pay, and the government wants reasons why (and actual evidence that the money did anything). At present both the Clinical and Counselling colleges (the psych people) and the medical people (i.e., the AMA) need to justify why there is such a blow-out in costs, and when this happened, everyone was surprised to see the doctors taking more of the pie than the people that actually do the work. Now it’s no doubt all of these groups are probably rorting the system as much as they can (and they’re just as bad as each other — for example, as soon as the clinical college got gifted with all the medicare money, they suddenly tried to make it really hard to become a member), but the doctors appear to be quite bad offenders. Most of the finger-pointing is of course done in the quietest possible manner since it’s in no-one’s interest to have the government cancel all the medicare rebates, which is probably why you don’t hear much about it, or perhaps it just isn’t a topical issue (alternatively, it is easy to find out that the cost is massively over what was budgeted, and that the money hasn’t gone to who really needs it, which is where all these problems come from).
Perhaps my perspective is biased, since I usually here from the psychologists complaining about the doctors rorting the system and not vice-versa, but it’s definitely getting rorted.
conrad
18 Jul 10 at 4:54 pm
The best thing for depression is probably to encourage (if they need it) GPs to prescribe antidepressants to anyone who seems depressed in a 5 minute consultation and then see the patient every couple of weeks to make sure they are taking it.
There would be a lot of over-prescribing but, probably, quite a few lives saved. And probably not much harm done, except to the PBS budget.
I am not suggesting that this is a good thing but it is probably better than we have now.
Or perhaps it isn’t far from what we have now.
ken n
18 Jul 10 at 4:58 pm
You are probably not far wrong conrad.
I’m not sure what “rorted” means anymore. The government makes the rules and people are going to play by them.
ken n
18 Jul 10 at 5:01 pm
“I’m not sure what “rorted” means anymore”
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Geoffrey Edelesten comes to mind as analogy, except not done as well.
conrad
18 Jul 10 at 7:29 pm
What are you on about Judith, those things are great. It says so on the DOH website:
“It is intended that each GP Super Clinic will bring together general practitioners, nurses, visiting medical specialists, allied health professionals and other health care providers to deliver better health care, tailored to the needs and priorities of the local community.
GP Super Clinics will support primary health care providers to adopt models of care focused on best practice integrated multidisciplinary team based approaches and efficient and effective use of technology. GP Super Clinics will provide a greater focus on chronic disease prevention and management, as well as economies of scale in delivering high quality health care.
GP Super Clinics are also designed to help address one of the key areas of inefficiency and duplication in our health system by improving integration between Commonwealth funded primary care services and State and Territory funded services, both community health and hospital. In line with this objective, the Australian Government is working closely with the State and Territory Governments in the implementation of this program.
GP Super Clinics may also provide a high quality clinical training environment for medical, nursing and allied health professional students and new graduates, in addition to prevocational doctors and GP registrars.”
pedro
18 Jul 10 at 9:41 pm
GP Super Clinics are a triumph of hype over reality. All they amount to is a generous bricks-and-mortar handout to the lucky winner of a secret selection process. The locations of Super Clinics are not based on any objective measure such as lack of access to a GP but they are all in marginal constituencies. The GP Super Clinics promise a great deal but actually deliver little more than the medical centres that are already in those locations, and they often duplicate services, (hence the ridiculous situation of the new Super Clinic in NSW resorting to poaching patients from established practices).
GP Super Clinics are supposed to offer a ‘one stop shop’, but they face exactly the same problems in recruitment and retention of staff as other medical centres. It would have been better by far if the govt had offered this money in the form of additional incentives/infrastructure grants for medical centres, instead of these white elephants.
Tom
19 Jul 10 at 2:26 pm