In his review of the Medicare Locals in 2014  Professor Horvarth concluded:

“I found lack of clarity in what many Medicare Locals are trying to achieve, with considerable variability in both the scope and delivery of activities. This has resulted in inconsistent outcomes across Medicare Locals, dispirited stakeholder engagement, poor network cohesion, and reduced sector influence. This lack of clear purpose has perpetuated a sense of confusion and relevance with service sectors, governments and the community.”

If the term “Medicare Locals” were to be replaced with the term “PHNs” would Horvarth’s analysis still hold in 2018? Have we been able to achieve a clear purpose with a unifying narrative across the country?  – or is it too soon to expect this?

The review went on to say the following and PHNs might do better on this score citing considerable progress in realising Horvarth’s vision:

“PHOs must be patient focused. To achieve this, PHOs should work collaboratively with GPs, LHNs and other providers to establish care pathways that facilitate appropriate and innovative health care to ensure better patient experience and outcomes. PHOs should be designed on a series of principles that facilitate their establishment as effective and efficient organisations, including strong skills based Boards, clear performance expectations, flexibility to respond to their regional and local context, and broad and meaningful engagement across sectors.”

About the three-point remit of the PHNs

The Commonwealth’s PHN website leads out with this:

“PHNs have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients,  particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time.  “

Let’s take each point in turn:

1.  increasing the efficiency and effectiveness of medical services for patients,

What stands out for me is the use of the term “medical”.  It reflects the view of the architects of the PHNs that GPs are indeed meant to be the ongoing cornerstone of the primary health system.   There is logic in this when one considers that General Practices are highly distributed across the nation and are visited annually (reportedly) by 8 in 10 Australians.  This is clearly a very good place to start if one wants to reform primary care.  However, cornerstones, in architectural terms, are meant to carry the weight of the entire structure. So when we refer to GPs as the ‘cornerstones’ it is at once both an endorsement and a challenge.  For some this is a burden that they won’t want to carry for a great many reasons- hence the importance of identifying GP change champions and doing all we can to help them assume this vital leadership role.   You might want to check out some of the clinician leadership and mentoring services available.

It is noteworthy for me that the term is “medical”  not “health”.  Yes we do indeed  need more than doctors to deliver optimal outcomes for sick people but I feel that PHNs are obligated under their funding deeds to do this with and through progressive GPs.  These GPs, with a reformist sensibility, are likely to have natural referral networks of allied health providers of a similar mindset and this provides PHNs with the real opportunity to leverage whole-of-system change.   We meed to “go in” to those practices exhibiting leadership before “going out” to support complementary change in other professions including pharmacy, allied health, aged care, etc.

2. particularly those at risk of poor health outcomes, and

In the context of disease burden it is the increasing numbers of people living with complex multi-morbid  chronic conditions that are at greatest risk of poor health outcomes.  Regrettably it is our first Australians who are most over-represented in this group.

This emphasis on those who are already sick is significant.  It suggests that PHNs are (at least initially I presume) to focus on the higher acuity end of the spectrum- not the preventative end.  I am aware that my analysis sits uncomfortably with some in the PHNs and this is reflective of philosophical tensions between those aligned with the Medical Model of Health Vs the Social Model of Health- and I get that.  However, one cannot argue, that at least in the current triennium, the Commonwealth has mandated a focus on patients at imminent risk of hospitalisation.

We do have opportunity however to appropriately focus on “secondary prevention”  and this provides a future entree to primary prevention including health promotion.   The Health Care Home model must necessarily incorporate secondary prevention and this may afford clinicians and care coordinators with the opportunity to undertake opportunistic health promotion with the family members of enrolled patients.  Yes, PHNs can and need to secure future influence and expertise in preventative health but this cannot compete with the core remit – a focus on those who are already sick.

3. improving coordination of care to ensure patients receive the right care in the right place at the right time.

As a fellow commentator observed “care that is not naturally integrated is not care at all”.

This objective set by the Commonwealth gives the PHNs both the mandate and the responsibility to be “system wranglers”.  With extremely limited fund-holding it is only through deft sector partnering that we will be able to garner the influence required to have patients experience a seamless and safe journey across the “daisy chain” of sector providers that is the Australian health system.  It hardly meets the technical definition of a system – that is,  involving a process with known actors, delivering known inputs, through known processes to deliver known outputs, resulting in known outcomes – all subject to a corrective performance feedback loop designed to achieve continuous quality improvement.   Clearly the Australian healthcare system that we have come to love, and happens to be one of the better performing “healthcare systems” in developed countries, does not meet this definition.

Improved co-ordination of care is predicated on provider integration as well as sector integration.  To fulfil its remit a PHN must necessarily be working all levels simultaneously-  hence the need to commission with precision.

The upshot of this article

These three objectives, taken collectively, constitute the remit of the PHNs in their current form.

If your PHN is not:

• Engaging deeply with selected reforming GPs
• To support patients with disease-difficult  chronic conditions
• Through enhanced care co-ordination

….  then what are you doing?

The answers to this will be many and varied and no doubt PHNs across the nation are engaged in many worthwhile activities –  but the question is are these the things that the Commonwealth has funded PHNs to do?

The Commonwealth needs to take some responsibility here as well with their penchant to make PHN’s “fixers” for emergent issues often with local political under-currents. The Commonwealth needs to play its part also in allowing PHNs to pursue their contracted objectives so that they can establish clarity as to their role and function during the turbulent times to come.

I don’t have line of sight on the funding deed for the next triennium so it will be interesting if anyone knows if the PHN’s remit is to change.

Also, I am interested to know what effect the Ernst and Young / UNSW National Evaluation of the PHNs will have on the future functions of PHNs.