ARE WE CLOSING THE GAP?

By ACTML CEO, Leanne Wells and ACTML Closing the Gap Program Manager, Dawn Nusa

I listened this week with interest, and frustration, as Prime Minister Tony Abbott told Parliament that Australia is “not on track to achieve the more important and more meaningful targets” in disadvantage of our First Peoples.

He made these comments while releasing the 2014 Closing the Gap report that disappointingly there’s been almost no progress in closing the life expectancy gap.  Six years ago the Council of Australian Governments set specific targets for closing the gap between the First Peoples and non-Indigenous Australians.

In terms of life-expectancy, the goal is to close the gap with a generation – by 2031.  There’s been little progress in this area, in fact the life-expectancy gap remains about a decade.  Right now Indigenous men die more than 11 years younger than non-Indigenous men; and Indigenous women ten years earlier than other Australian women.

 

 

Australia’s first Indigenous Federal MP Ken Wyatt said “one of the health reforms I’d like to see is a sharper focus on frontline services, improved access to primary health care”.

I couldn’t agree more.  We know that substantial investment in the primary health care sector, such as community-based chronic disease management, can prevent people from entering hospital in the first place.  Primary health care benefits provide better value for money and outcomes than non-primary care approaches.

Health equality is an issue of national importance.  Locally ACTML is committed to improving the access our First Peoples have to medication, allied health professionals, medical specialists, medical equipment and transport.  Our Care Coordination and Supplementary Services (CCSS) team – and care coordinators within the Winnunga Nimmityjah team are funded under the Indigenous Chronic Disease Program and work closely with clients and their GPs to facilitate just this.

Chronic disease accounts for two-thirds of the premature deaths among our First Peoples.  That’s why the CCSS program targets people with cancer, diabetes, cardiovascular, respiratory or renal disease.

The programs are working closely with clients and their GPs to integrate and coordinate care.  The Nuffield Trust, an independent source of evidence-based research and policy analysis for improving health care in the UK, has shown integrated care assists individuals where gaps in care, or poor care co-ordination, leads to adverse impacts.  Integrated care is particularly helpful for people with chronic disease.

 

 

We know that care co-ordination is an effective service integration tool.  Care Coordinators are assisting local Aboriginal and Torres Strait Islander Peoples in an on-ground, grass-roots way each and every day.  It starts by building trust with their clients which increases the ways in which they can help them.  Without trust, you have nothing. The Care Coordinators assist to ‘navigate the system’ in the most practical and culturally sensitive way.  Appointments are made with appropriate health professionals, and patients are often accompanied to their appointments.  These practical things make all the difference to access.  We’ve seen first-hand the benefits of linking patients in with culturally sensitive and accessible health – either at Winnunga Nimmityjah Aboriginal Health Service or at a general practice.

The Prime Minister said that Indigenous affairs are close to his heart at the same time as acknowledging there’s a long way to go.  In the meantime, we’ll keep integrating care at a local level and supporting our clients.

PRIMARY MENTAL HEALTH CARE REFORM: THE TRANSLATIONAL AND TRANSFORMATIONAL ROLES OF MEDICARE LOCALS

Medicare Locals (MLs) are strengthening the primary health care system. We do that in many ways.  We introduce new services that are innovations in their own right, we work to build the nature and scope of the primary health care workforce, and we translate evidence into local solutions.

NewAccess,is a new mental health service based on the highly successful UK NHS program, Improving Access to Psychological Therapies (IAPT) that demonstrates this translational and transformation role of MLs.

Only a third of Canberrans with depression and anxiety have access to appropriate psychological services.  We’re working to combat the issues of cost and stigma as barriers which continue to be main barriers to mental health support.

 

 

We’re proud to be the first Medicare Local to offer the new beyondblueprogram, NewAccess, funded by both beyondblue and Movember.  Since it commenced in October last year, our Access Coaches have provided free assistance to over 185 Canberrans who have mild to moderate depression or anxiety.  It’s rewarding to see locals with mild symptoms of these common mental health issues take early action and receive free low-intensity assistance.

NewAccess aims to increase the number of hard-to-reach populations receiving help, particularly men.  Clients can easily self-refer by calling 6287 8060 or be referred through traditional channels such as GPs

Drawing on the success of the IAPT program in the UK, NewAccess was created to provide clients with a first line treatment, based at the community level.  As a result of the flexible referral pathways and flexible intervention methods including the use of brief low intensity cognitive behavioural therapy (CBT) interventions and guided self-help over the phone, the program has been highly successful, with it reducing the burden of existing services and having a significant recovery rate.

The NewAccess program is developing and training a new workforce in Australia.  ACTML is currently employing five community-based Access Coaches who have received intensive training around Low Intensity Cognitive Behavioural Therapy, guided self-help activities and social prescribing through Flinders University.  This program acts as the first line of treatment for people with mild symptoms of depression and anxiety, before there is the need to utilise clinical services.

 

 

Our Access coaches are helping clients set practical goals to get them back on track. I was speaking with one of our Access Coaches the other day.  He was telling me about a client who came to NewAccess after a referral from his GP stating that he’d stopped doing things he enjoyed because he’d been feeling depressed for the last few months after losing his job and breaking up with his girlfriend.  After booking an appointment with NewAccess and speaking to one of the Access Coaches, he was able to understand how and why he was feeling the way he was, and the impact this was having on his life.  Over the next few weeks he was able to engage in the behavioural activation techniques that had been explained to him by his Access Coach, and found that this helped significantly improve his mood.  By the end of his six sessions, he was back to doing all the activities he used to enjoy as well as actively looking for work.

NewAccess is adding to the important services already available to the Canberra community through ACTML and others and is helping to strengthen the support for those living with a mental health issue.

In collaboration with partners we’re helping more Canberrans access appropriate help for their mental health concerns, whether it be for mild depression and anxiety, through to severe and persistent mental illness.  It’s all about ensuring that people with mental illness – no matter how severe – have access to the services they need and are supported to lead a contributing life.

ACTML is conducting a Comprehensive Needs Assessment for the ACT.  Our consultations will pinpoint mental health as a priority theme and enable us to co-design how we can further improve primary mental health services for Canberrans.

EHEALTH RECORD SYSTEM – BUILDING BLOCKS FOR INTERCONNECTED CARE

The transfer of patient information between healthcare providers for better continuity of care is nothing new.  This information has traditionally been transferred via face to face interaction, phone, fax, unsecure email or by postal mail.  Some of these methods of communication have posed security and privacy risks, high costs (both financial and to the environment), and time delays.  The advent of eHealth technologies to transmit patient information offers processes which are both secure and efficient.

eHealth initiatives currently include approaches that can be used as building blocks for interconnected care such as secure messaging (including eReferrals, eReports and eDischarge Summaries) and the Personally Controlled eHealth Record System (or ‘eHealth Record’).  Secure messaging and the PCEHR offer ways for patient information to be electronically transmitted and shared securely.  This can be direct from the GP’s clinical software which decreases the risks associated with more traditional methods such as information inaccuracies through poor transcribing or ineligible hand writing.

While both secure messaging and the eHealth record offer solutions for the transmission of patient data, they are dependent on technical factors that have to work to connect different systems. Getting the technical issues sorted out can delay the implementation and uptake of these initiatives.

 

 

Secure messaging between general practice and some specialists has been occurring in the ACT for over 2 years. Those involved have seen improvements in the quality of information exchanged.  Experience tells us that not all messages are sent via secure messaging straight away, and it can take time for an organisation and their staff to become comfortable with this new way of communicating with their colleagues.

Improved technologies enabling secure messaging to and from allied health clinicians have recently become available.  ACTML is currently working with a small number of allied health professionals to guide them through the possibilities that secure messaging has to offer.  This includes being able to securely receive electronic referrals that are generated directly from the general practice software.  Allied health clinicians are enthusiastic about the potential this presents in terms of providing better patient information.  GPs can generate these referrals from their clinical software systems with the click of a button.

The eHealth Record is not intended to replace the clinical records that are currently held by healthcare providers.  What it does do is provide a central place where a patient’s most important health information can be shared with other providers that need to access it.  For example this technology enables hospital medical staff or GPs on the other side of the country to access a health summary which has obvious benefits for patients and clinicians alike.  The benefits are real.

ACT’S FUTURE PRIMARY HEALTH NETWORK – OPPORTUNITIES GALORE

Ms Leanne Wells

Dr Paresh Dawda

The Budget brings Medicare Locals short life to an end in June 2015.  Their function as a primary health care organisation will be replaced by Primary Health Networks (PHNs).  Successful PHNs will be announced next year, following an open contestable process; the details of which are expected in Spring.  The ACT Medicare Local  (ACTML) will tender to be the ACT’s PHN.  For the ACTML this is a natural progression in a unique jurisdiction and the reforms offer a springboard to the next level.

The ‘Horvarth’ Rert has been endorsed by the Federal Government and provides a window on the specification for PHNs.  The expectations include a paramount role for general practice as well as other primary care providers.  A key function will be to integrate care across the whole health system leading to improved patient outcomes.  Where services gaps exist, they will commission those services rather than provide them (unless there are exceptional circumstances).

The starting point for this journey of integrating care and improving outcomes is to understand the current state.   The ACTML’s comprehensive needs analysis provides that understanding and has been launched by the ACT’s Chief Minister and supported by the ACT Government.  It has been produced following a systematic process and articulates the current and future needs. It will evolve to include more detailed snapshots of health status and needs at sub-regional levels, in natural catchments such as Belconnen and Tuggeranong.

 

 

As Canberra’s population grows older and experiences an increasing prevalence of chronic conditions and multi-morbidity, some of these needs are not surprising.  They include:

  • improving access to care, particularly for vulnerable groups like the elderly and homelessness;
  • a need to prevent chronic diseases where possible;
  • support patients to manage those chronic conditions well if they do develop;
  • for those patients with more complex needs to improve the coordination of care;
  • and the accurate and timely transfer of clinical information.

Services need to be more integrated and seamless from a consumer perspective.  The health reform affords the opportunity to operate under one common strategic framework, together with the ACT Government, so all our efforts are aligned to tackling the same common shared goals as one system.  To bring together the different organisations that make up the system will require strong relationship based frameworks.  Where gaps in the population needs require additional services, a joint commissioning approach will be actively explored with an intent to underpin those strong relationships and common goals with innovative contracting arrangements that could, over time, pool resources, share risk and provide joint governance.

PHNs are primary health organisations, which operate at a meso level of the health system.  Many countries including New Zealand, UK, Canada and US have such organisations.  In some countries those organisations have evolved from primary care provider needs. In other countries, as in Australia, governments have introduced them.   Irrespective of their origin, their critical success factor is simple:  to engage and support its clinical community in delivering effective and high quality services for their patients.

 

 

As simple as it sounds, achieving this in meaningful way is challenging but certainly possible.  The ambition is a bottom-up approach supporting clinicians every step of the way, with enabling processes that make their jobs easier to perform and allow them to focus on the clinical care for their patients.  Specific projects like HealthPathwayswill be a great enabler, but alone will not be sufficient.  In some cases new tools or infrastructure will help.  In other cases, new services will be needed; in others existing services will need to redesigned or improved and to achieve this will require a new set of skills.  Supporting practitioners to develop these new skills will be a priority.  These new services, such as a health coach for patients with heart disease, may be housed in the medical centres where consumers usually receive most of their care, or where a wider team is required, in the ‘medical neighbourhood’.

ACTML has taken an engaging approach in thinking about the future direction.  It has listened to its members, the community, clinical leaders, consumers, and other stakeholders.  It has heard that it has strong foundations, but the complexity of health is changing, and hence it will build on those foundations.  There are opportunities galore to improve the health of our citizens.  Working together and collaboratively across the broad spectrum of public and private, government and non-government stakeholders we can seize those opportunities as a PHN.

VISION FOR MENTAL HEALTH IN CANBERRA FOR THE NEXT DECADE

By ACTML CEO Leanne Wells

Mental health is one of the most important and most vexing areas of health policy and service development. The effects of mental ill-health can be profound and wide-reaching for individuals, families, communities and economy.

Right now, the mental health system is under scrutiny by the National Mental Health Commission. I understand the Commission has lodged its final report with the Federal Health Minister and that it may be published soon.  Locally, here in the ACT, the Government is consulting on a whole-of-government Mental Health and Wellbeing Framework 2015-2025.

 

 

ACTML has made submissions to both these reviews. Our messages are clear. To the Commission we said that Australia must have strong, evidence-based mental health care services and programs delivered at the primary care level. The common and often most disabling conditions long-term such as depression and anxiety are best managed in a primary health care setting by general practice working in teams with specialist mental health services and supported by relevant community services to provide integrated, coordinated, ‘wrap-around’ care.  This is the model of care we should invest in, not more beds.

We urged the Commission to promote the lead role that regionalised primary health care organisations (PHCOs) can play. Medicare Locals, and before them, the divisions of general practice established, coordinated and integrated new services such as the Access to Allied Psychological Services Program (ATAPS) and headspace with the rest of the system.  Primary Health Networks (PHNs) will have the same, if not greater, promise. As regional commissioning organisations, they will have the capacity to make federalism work at least at the point where Commonwealth and State/Territory responsibility in primary health care intersects. Their promise in this space should be supported through pooling of funding and ‘alliance commissioning’ approaches especially if we want to see real flexibility, integration, responsiveness and innovation in primary health care. Primary Health Networks will replace Medicare Locals as Australia’s regional system of primary health care organisations from 1 July this year.

 

 

We suggested three practical steps for change:

  • a joined-up approach between Local Hospital Networks and Medicare Locals/PHNs to whole-of-system planning, design and development of localised mental health services that span the full spectrum of care.
  • aggregate and devolve all funding for primary mental health care programs in a single flexible mental health fund to commission services in the configurations and mix that best match local need. This will go a long way to fostering services that are focused on the whole person and to commissioning services with the whole system in mind.
  • the development and implementation of a full suite of localised mental health pathways through co-design by appropriate primary care and specialist clinical leaders and embed them in HealthPathways where this initiative exists in local health systems.

Closer to the ground, to the ACT Government we said that ACTML strongly supports the development of whole-of-government Mental Health and Wellbeing Framework 2015-2025. However, we risk this Framework being a missed opportunity unless it takes a “different not more” approach. This should involve steps such as:

  • a governance approach to the Framework’s development and implementation oversight that commits relevant ACT Government Directorates to action and mirrors that taken with the development of the ACT Human Services Blueprint. This process saw Directorates and community sector leaders coming together in a single taskforce to co-design the Blueprint. Consumer and carer involvement in co-creating the framework is a must
  • a boost in strategies and shift in investment to expand early intervention and primary and community-based mental health care services
  • building in and continuing to invest in promising, results-oriented early intervention models of care such as the beyondblue and ACTML supported NewAccess low-intensity psychological service and positive parenting programs, another area where the evidence is extremely strong
  • the introduction of a shared care model to improve integration and transition between primary, secondary and tertiary services, improve consumer experience (particularly to better support the management of physical and mental health comorbidity) and reduce costs associated with re-referring and mistakes in system navigation.

Mental ill-health will continue as a major challenge for policy makers, clinicians, NGOs and communities. It is time for brave new policy at both Federal and State levels and one that recognises that investment in primary mental health care will be the lynchpin to a stronger and more responsive system of care overall.