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Open Access Article << Previous     |     Next >>   Contents Vol 34(1)

The future of community-centred health services in Australia: lessons from the mental health sectorA

Alan Rosen A D, Roger Gurr B, Paul Fanning C

A Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.
B Faculty of Medicine, University of Western Sydney, Penrith South DC, NSW 1797, Australia.
C Centre for Rural and Remote Mental Health, School of Medicine and Public Health, University of Newcastle, Orange, NSW 2800, Australia.
D Corresponding author. Present address: PO Box 110, Balmain, NSW 2041, Australia. Email: alanrosen@med.usyd.edu.au
 
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Abstract

• It is apparent that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy.

• Community-centred health care has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions. Nevertheless, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services.

• The reasons for these trends are explored.

• The future of community health services in Australia is uncertain, and in some states under serious threat. We consider lessons from the partial dismantling of Australian community mental health services, despite a growing body of Australian and international studies finding in their favour.

• Community-centred health services should be reconceptualised and resourced as the centre of gravity of local, effective and affordable health care services for Australia. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services.

What is known about the topic? Community-centred health care has been widely demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions, e.g. in mental health service systems. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services.

What does this paper add? Despite this global consensus, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. The reasons for these trends and possible solutions are explored.

What are the implications for practitioners? Unless this trend is reversed, the loss of convenient public access to community health services at shopping and transport hubs and the consequent compromising of intensive home-based clinical care, will lead to a deterioration of preventative interventions and the health care of long-term conditions, contrary to international studies and reviews.


A A more detailed version of this paper was invited by Professor David Richmond, AO, then NSW Coordinator General of Infrastructure Development, NSW Department of Premier and Cabinet, and member of the Health Infrastructure Board, to stimulate discussion around the themes of integration and balance between hospital and community healthcare, as these issues confront all Australian states and Federal Government and other comparable international jurisdictions. He is currently Consultant on Infrastructure and Public Policy to NSW Department of Premier and Cabinet.

B Capital charging: the essence of capital charging is that the costs of capital facilities should be rendered explicit. This transparency is intended to introduce new discipline to decisions about the acquisition, use and disposal of publicly financed assets.79,80 In an environment of contestability between public and private services, there should be equitable accounting for the capital used in providing services and the cost of servicing that capital. This provides a driver for making efficiencies in the use of land, buildings, and equipment, which leads to selling off properties which may be designated as surplus to needs. In health administrations which assume the centrality of hospitals to the delivery of health care, this results in the financially penalising of area and local health services for operating from multiple sites, and forcing consolidation to fewer (and inevitably hospital) sites.

C Case example. A recently approved emasculated version of a ‘HealthOne’ integrated primary health care community health clinic at Chatswood in urban NSW, invited GP’s to co-locate in a few rooms of a small community ‘spoke’ or ‘outpost’ centre which can be booked for sessions interchangeably by visiting community health workers. They are to be otherwise firmly based at a ‘hub’ which comprises a 9 storey ‘community precinct’, some kilometres away on a major general hospital site, 13 minutes walking distance from access to their community health cars. It appears unlikely to provide comprehensive service coverage, nor a critical mass of staff to sustain a viable community health service, nor a viable referral base for GPs. The Local GP Network rejected this diluted version of what otherwise could have been a sound primary and community healthcare delivery model, but only if most aspects of community health had continued to be squarely based at the Chatswood community site. This outpost centre, now being built, may be only being placed in Chatswood gesturally to ‘end community speculation’ (according to the Ministerial press release) concerning the shifting of a formerly large community health centre from this major shopping area onto the more distant hospital site. This will then enable NSW Health to sell most of this valuable community site to contribute to the rebuilding of the hospital. The new centre is likely to become a white elephant. The devolved community health polyclinics, proposed by Darzi for the NHS in London, in high streets near the main shops and transport interchanges, with substantial and stable staffing, or similar integrated primary and community health centres in Portugal, would be much more likely to attract a critical mass of GPs in shared or adjacent premises.
   


    
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