Introduction by Croakey: ‘Every system is perfectly designed to get the results it gets’ is an insight often repeated across the health system.
One of the reasons that so many Australians find their healthcare to be fragmented and difficult to navigate is because of how funding systems are designed.
However, the Eastern Melbourne Primary Health Network is making determined efforts to develop a new funding model that better supports integrated care, and its approach may be of wider use, suggests Professor Stephen Duckett AM, Chair of the Board of Directors of EMPHN.
“The EMPHN approach is not a panacea. There are still significant programs outside the scope of the funding streams being brought together through this model, and no single commissioning reform can overcome all the structural divisions across Australia’s health system,” he writes below.
“But combining more integrated commissioning, explicit consideration of population need and bonuses for better outcomes represents a significant change.”
Stephen Duckett writes:
A new $30 million commissioning model in Melbourne’s east and north is testing whether integrated care can be built into the way services are funded, rather than left to consumers to navigate.
Imagine being an older person living with diabetes and heart disease who is also experiencing anxiety. Or a young person dealing with mental ill-health alongside other health and social challenges.
The health system might see several different conditions, programs and funding streams. The person experiencing these sees one life.
Yet too often, getting help means navigating different services, repeating your story, working out who provides what, and encountering eligibility rules and referral pathways that make sense to the system but little sense to the person seeking care.
For decades, we have talked about “holistic” and “person-centred” care. But it is difficult to deliver truly integrated care when the way we fund and commission services remains fragmented.
Talk to almost any community sector provider and they will describe the same problem from the other side. Community health managers can find themselves juggling multiple programs, each with separate performance measures, reporting requirements and funding timelines.
For primary care and much of the community sector, fragmented care is not a bug, it is a feature of how the system has been designed.
Eastern Melbourne Primary Health Network (EMPHN) is trying to change that for the 1.5 million people living in Melbourne’s east and parts of the north.
EMPHN receives about $30 million a year from the Commonwealth Department of Health, Disability and Ageing for a range of primary care services across 12 separate funding lines, each with its own requirements.
Like other commissioning organisations, EMPHN has historically had to translate these different funding streams into services while meeting the requirements attached to each of them. The result is a familiar challenge: while everyone wants integrated care, the architecture sitting behind it can work in the opposite direction.
An opportunity
A careful review of EMPHN’s Commonwealth funding agreements, however, revealed an opportunity.
The 12 programs could be grouped around four main outcomes: adult mental health and wellbeing, youth mental health and wellbeing, chronic disease management, and stronger aged care.
Of course, it is one thing to identify fragmentation and another to work out how to fix it. Extensive consultation with consumers, providers and other stakeholders helped shape the new model and, importantly, test whether a different commissioning approach could make care easier to deliver and navigate.
EMPHN decided to use these four outcomes as the commissioning frame, bringing services together through place-based contracts covering the eastern, northern and southern parts of its catchment.
Contracts for the successful providers were announced this week.
EMPHN remains accountable to the Commonwealth for the original funding requirements. But rather than expecting providers to operate across 16 separate program silos, the new model gives the successful consortia accountability across four broader program areas.
That shift matters because it creates greater scope for services to organise care around people and communities, rather than around individual funding streams.
The new approach has also created the opportunity for two other important changes.
First, funding is being more explicitly allocated across the three geographic areas according to population health needs assessment. This means resources can better reflect differences in need and population growth across Melbourne’s east and north.
Second, the funding model has been updated to include activity and outcome components. In other words, the focus is not only on how much service is delivered, but increasingly on what difference that service makes.
The new arrangements will be phased in over six months, recognising that reforming the funding architecture should not come at the expense of continuity of care for people already receiving services.
Every time a politician has had a bright idea in the past, there has been a temptation to create a new program and a new funding stream to accompany it. Individually, each of these decisions were well intentioned. Collectively, this programmatic confetti has contributed to a system that can be extraordinarily difficult for consumers to navigate, and leads to waste, duplication, and gaps.
This is not the way the future needs to be.
Integration should not be a slogan. Nor should we expect individual clinicians and service providers to somehow overcome fragmentation that is embedded in the way the system itself is funded.
New programs should build on existing infrastructure and recognise that people frequently have multiple and overlapping health needs. If we want consumers to be treated as whole people, our funding and commissioning arrangements need to see the whole person too.
The EMPHN approach is not a panacea. There are still significant programs outside the scope of the funding streams being brought together through this model, and no single commissioning reform can overcome all the structural divisions across Australia’s health system.
But combining more integrated commissioning, explicit consideration of population need and bonuses for better outcomes represents a significant change.
Hopefully this sets a precedent for others to follow, beyond just the PHN world.
Author details
Health economist Emeritus Professor Stephen Duckett AM is Chair of the Board of Directors of EMPHN. He has held senior executive and governance positions across government, higher education and the not-for-profit sector.
His career includes serving as Secretary of the Australian Government health department, Professor of Health Policy at La Trobe University, Chief Executive Officer of Alberta Health Services, and Director of the Health and Aged Care Program at the Grattan Institute.
See Croakey’s archive of articles on PHNs
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