By Jim Gillespie, University of Sydney
The former Labor government’s GP Super Clinics Program has come in for a bashing.
The Coalition has derided it as “a total waste of money” and News Corp has dubbed it a “dangerous health care experiment” because it diverted funding from public hospitals.
The former government committed A$650 million to build more than 60 GP clinics, 39 of which are currently operating. Health minister Peter Dutton justified the recent cancellation of three clinics and a review of 12 other proposed sites by likening it to the failures of the pink batts scheme.
But is this a fair assessment? Let’s consider what GP super clinics were set up to do – and where they’re making progress.
Better integrated care
The GP Super Clinic Program was one part of a suite of reforms across the Australian health sector introduced by the Rudd government in 2007.
At the time, the new demands of an ageing population – with a growing burden of complex, serious and continuing illness – were not being met by existing fragmented forms of primary care. This meant patients who could be cared for in the community were being admitted to hospital for care at a much higher price.
Research in Australian primary care was also falling behind, particularly in connecting universities with clinical general practice. And links between general practice and hospitals needed boosting to improve the safety and quality of patient care.
Past attempts to achieve reform by straight subsidy of existing general practice – through the Practice Incentives Program, or by funding new services through the Medicare Benefits Schedule – have proved disappointing. Few GP practices can afford to do this additional work around research and education. It costs money and financial support, well outside the business models of smaller clinics and corporate for-profit clinics.
Super clinics aimed to build more integrated care through a public-private partnership. Successful tenderers received capital grants from the Commonwealth government to construct new clinics in under-served areas. The super clinic model, it was hoped, would bring GPs, nurses, physiotherapists and other allied health professionals under the one roof.
The idea was that the clinics would train the next generation of primary health professionals. And they would use the most advanced e-health systems and develop a research focus that was lacking in Australian primary care.
The first 32 super clinics were announced in the heat of the 2007 election campaign, many in marginal electorates. An Australian National Audit Office (ANAO) report later criticised this rushed and politicised decision-making, saying it led poor planning and delays in construction.
Many super clinics did not fill gaps, but duplicated existing services, leaving local GPs fuming at the unfair competition. Some of the promised new services – such as extended hours so patients could see a GP in the evening rather than going to an emergency department – proved too difficult and were abandoned.
The ANAO found services were often less innovative than planned. Little use was made of nurses’ underused skills (and lower cost) to perform traditional GP tasks.
The funding model was also a problem. The government paid for new buildings, but the super clinic was expected to be self-funding, relying on Medicare payments like every other GP. This has often proved too little to pay for the promised levels of service, staffing and opening hours.
The roll-out of clinics has remained slow. Of 64 announced since 2007, 39 are operating, 14 are under construction and 11 still in the planning stages. The Mt Isa Clinic, announced in 2007, suffered repeated funding disputes and is now due to open in mid-2014.
After major financial difficulties, the Redcliffe Super Clinic opened in January 2014 but remains half empty. It’s still struggling with the difficulties and costs of attracting staff.
But it’s important to put these criticisms in perspective. International experience (including in Australia) has shown that integrated care requires very slow implementation, drawing in existing services and building trust.
Other countries have also learnt the hard way that top-down capital works based programs, often with politically inspired choices of locations, are usually a recipe for failure.
As the GP Super Clinic program matures, we’re learning that one size does not fit all, particularly with the different demands of rural, regional and metropolitan practices.
The super clinics that have got off the ground are using a variety of business and clinical models.
The three clinics run by the University of Queensland aim to provide leadership and influence through innovation in education and research, and to develop innovative models of care particularly around chronic and complex conditions. UQ Health Care has been operating for four years, and has met a number of targets. It employs 20 GPs and sees close to 60,000 patients per year.
Ochre Health – which already had experience with comprehensive primary care in regional NSW and Queensland – now has three super clinics which opened on schedule and seem to be achieving many of the program’s objectives. These clinics work on a co-location model, bringing GPs together with other health professionals. The clinics work with seamless e-health records, connecting to local hospitals with broadband connections.
The large new Ochre Sunshine Coast GP Super Clinic, co-located with University of the Sunshine Coast, has space for teaching and placing a range of disciplines – not just doctors and nurses but also allied health students who can have a hard time getting placements. The recently opened second ACT GP Super Clinic, run by Ochre, has a similar relationship with the University of Canberra.
The Wanneroo clinic, in Western Australia, has confronted the limitations of existing funding models. It is led by Edith Cowan University, with a A$12 million investment, matched by A$5 million each from federal and state governments. When the clinic opens later this year it will include general practitioners, nursing, midwifery and allied health services, Aboriginal health workers and visiting specialist services. This will relieve pressure on the nearby Joondalup Health Campus.
These – possible – successes aside, a final judgement is difficult. There has been no proper evaluation of the program’s outcomes, other than negative reviews of administrative processes. Progress is mixed, at best, with serious mistakes and false starts.
A mature policy approach would be to carefully absorb the positive lessons and learn rather than score political points from past failings. International experience has shown there is no single model or easy that can deliver integrated care. It is a process that will require new funding models and must be led, managed and nurtured over time.
Jim Gillespie receives research grant funding through fthe University of Sydney from the NHMRC and Western Sydney Partners in Recovery.