Primary Health Networks: Towards commissioning for outcomes.

Abstract

It seems as yesterday when I wrote an editorial for this journal which ended by asking whether Medicare Locals would be part of the problem or part of the solution.1 Sixty-one Medicare Locals have come and (almost) gone replaced by 31 Primary Care Networks. The judgement was based on an independent report by John Horvath which pointed to systemic shortcomings in the operation of Medicare Locals, some of which were very good and others were less so.2 Medicare Locals were found to be inconsistent, bureaucratic and lacking in transparency, and some had overemphasised the provision of services and paid insufficient attention to the key role of General Practitioners (GPs) in their catchment. As independent organisations, Medicare Locals might disappear completely, they might reappear in disguise as service providers or they might change from chrysalis to butterfly and emerge as Primary Health Networks (PHNs). The PHNs will focus on commissioning primary health care services and supporting GP and other primary care services. The decision to fund 31 PHNs means that some PHNs will need to collaborate with as many as three local hospital networks. A key to effective commissioning is to have a clearly defined population for whom services are secured and to share that defined responsibility with appropriate providers. In rural and remote areas the PHNs will cover large, dispersed and sometimes heterogeneous populations necessitating multisite administrative systems or risking challenges to legitimacy due to excessive geographical and perhaps social distance from the populations served. Good commissioning depends on clear data about population needs and priorities, good information about service provider preferences and capabilities and good evidence about the effectiveness and efficiency of service models. One of the first tasks required of the now defunct Medicare Locals was to undertake or commission a needs analysis for their population to guide their activities. One would hope that the information systems available to the newly established PHNs mean that this activity will not need to be repeated. Commissioning usually involves securing activities or services that would not otherwise be provided such as allied health treatments, after-hours services, health promotion or education. Leading international health services are commissioning for outcomes in which providers share some of the risk and some of the rewards. For instance, if a commissioned service results in a reduction in emergency department attendances, hospital length of stay or earlier discharge to the community, the financial ‘gain’ is shared between the purchaser and the provider. Other sorts of gain might be achieved by the use of technology which results in a reduction in the number of face-to-face consultations and an increase in the number of patients who can be treated in low-cost and sometimes safer community settings such as their homes as opposed to high-cost and often risky institutional settings such as hospitals. Within fragmented health care systems, realising such gains through commissioning requires high levels of cooperation and collaboration between community members, public and private health care providers, state, Commonwealth and voluntary sectors. Such developments are often characterised by strong relationships between clinicians and system leaders that are sometimes found in rural communities. The ultimate test of innovations such as PHNs is the health and well-being of communities and the sustainability of health service and related systems. The ‘triple aim’ for health services incorporates patient well-being, population health, and economic performance, and implies that high-performing systems can simultaneously achieve improvements on all three dimensions. While we know that most high-performing health care systems have strongly developed primary care services it remains to be seen whether PHNs can provide, or even aspire, to the sort of system leadership that is needed to achieve improved and measurable outcomes. Rural settings provide a scale of population and service provision that is often amenable to innovation and change due to relatively small numbers of residents and providers. It is important that PHNs should commission for outcomes and that these outcomes should be measured and made public. This will require cooperation from public and private providers in both providing primary and secondary services. In an ideal world our information systems would provide these data as a matter of course. In the rural world our fragmented systems do not share clear and transparent objectives and so it is difficult to measure outcomes. Perhaps as a first step PHNs could negotiate clear health outcome objectives with appropriate communities and providers and these could be made public. If we know where we are going it will be much easier to measure progress and the criticisms that led to the abolition of Medicare Locals will no longer be appropriate.