Executive Highlights No 665

GP Super Clinics no solution to hospital ‘crisis’

Jeremy Sammut

GP clinics must do more than just plug gaps writes Jeremy Sammut in the Weekend Australian, 28 June 08

In these pages last November, I suggested that coordinated primary care for chronic disease patients was unlikely to lead to lower hospital admissions.

Various studies have found that the main effect of coordinated care is to uncover unmet need and identify new cases that require hospital treatment. In New Zealand, for example, the ‘Care Plus’ programme, which introduced coordinated care in a ‘real world’ setting, lead to a 40 percent rise in admissions.

But I hoped I got it all wrong. So serious are the problems in public hospitals – overcrowded emergency department’s unable to deliver timely and safe care - that surely the ‘crisis’ wasn’t being exploited by health reform and industry groups with vested interests in shaping policy outcomes?

But the time for evidence-based policy debate had evidently passed. The Rudd Government had just been elected on a promise to ‘end the blame game’ over hospitals and expand access to coordinated care through the planned national network of GP Super Clinics.

As far as alleviating the pressure on hospitals goes, the problem with the Government’s Super Clinics policy is that it accepts the well-cultivated myths that surround coordinated care. Theevidence does not show that focusing less on hospitals and more on primary care will, as the federal health minister’s favourite slogan goes, ‘keep patients well and out of hospital’.

For example, a 2002 study found that the US HMO Kaiser Permanente used hospital services at one-third the rate of British NHS. The Australian advocates of GP Super Clinics have attributed the lower ‘frequency’ of hospital use to the coordinated care delivered in Kaiser’s multidisciplinary health centres. Yet a 2004 study found that Kaiser’s programs had not produced the predicted reductions in hospital use.

Advocates of coordinated care have also trumpeted the results of the Second Round of the Australian Coordinated Care Trials. They say this showed that coordinating the care of patients reduced hospital admissions by 25% compared to a control group of patients whose care was not coordinated. What this measured was the difference in average rates of growth in hospital use in the trial compared to the pre-trial period.

But if you plough through the Commonwealth Department of Health and Ageing report on the trials, more questions are raised than answered. When the initial difference in pre-trial rates of hospital use between the two groups was adjusted for, you find that the so-called ‘substitution effect’ – coordinated care leading to reduced use of hospitals – disappeared. You also find that there was no real reduction in hospital use, because patients who received coordinated care also received ‘significantly’ more hospital services than did the control group.

Again, the evidence seems to demonstrate that coordinated care enhances primary care’s traditional roles of timely detection and referral to necessary treatment. Ensuring patients receive all beneficial care is hardly an argument against Super Clinics. But doesn’t this mean Super Clinics located in poorer and sicker socio-economic areas suffering doctor shortages, as is the government’s plan, will increase demand for hospital services and the pressure on struggling public hospitals?

Due to the bed cuts of the last 20 years, there simply aren’t enough public hospital beds to cope with the rising demand generated by ‘very old’ patients aged seventy-five plus. Emergency specialists suggest that the admission of the overwhelming majority of very old patients is next to inevitable and could only be avoided in very rare cases. If this is right, coordinated care will have little impact where it matters most.

Therefore reorientating the health system around Super Clinics and coordinated care doesn’t shape up as an evidence-based allocation of resources to fix the crisis in hospitals. The key challenge is to maximize the availability of hospital beds to cope with the coming tsunami of ‘very old’ patients requiring bed-based hospital care.

It may, therefore, be worth pondering the most important lesson of Kaiser Permanente. Compared to other health systems, Kaiser’s great advantage lies in breaking down traditional divisions between primary and hospital care. The principal reason for Kaiser’s superior capacity to more efficiently use hospital beds is that its health centres are specifically designed to provide patients with common specialities and testing in non-hospital community-based settings.

However, emulating these features of the Kaiser clinics doesn’t seem to be on the reform agenda. Instead, the national focus is solely on filling the gaps the primary care system, as demonstrated by the first report of the National Health and Hospital Commission, which recommends a Commonwealth expand its present responsibility for primary care by assuming responsibility for allied health.

The Rudd Government is determined to go ahead with Super Clinics.  The role they could play – along the lines of the Kaiser model – is worth investigating. Potentially, Super Clinics could improve the integration of the health system, smooth out patient journeys, and better manage demand for hospital admission - if they are equipped to substitute services currently provided in State-run hospitals.

Dr Jeremy Sammut’s report, ‘The False Promise of GP Super Clinics Part 2: Coordinated Care’, was released by The Centre for Independent Studies this week.
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