Rural and Remote
Vol. 23 No 2 | Winter 2021
Feature
Models of public care in regional settings
Dr Rosemary Buchanan
MBBS,FRANZCOG, AFRACMA

In October 2008, I moved to Winchester in England. I moved there to undertake my final year of FRANZCOG training, and accidentally stayed for five years, got married and had a baby. Regional Australian medicine was where my heart lay so I persuaded my husband, who was happy to live in the outback, to move to beautiful Mildura. During the course of my training, I worked throughout regional Victoria, Geelong, Bendigo and Wangaratta. I now live in Warrnambool.

I also trained in urban hospitals in Melbourne and worked in the UK’s National Health Service. This gave me experience across a large number of different service provision methods. I worked in both public outpatients and private clinics as well as mixed service providers.

In this piece, I contrast my experiences working within health settings that operated under a public and private partnership model with a mixed funding model. I reflect on what I found to be their strengths and weaknesses. The opinions presented are my own.

Conception of the public and private model for healthcare in Victoria-Mildura Base Hospital

The Kennett-led coalition, 1992–1999, has been described as adopting economic rationalist ideology more aggressively and with more enthusiasm than any other state government in Victoria’s history-or in any other government of an Australian state.1

In 1995, the Kennett government set out to privatise many previously state-run community services. Sectors under the spotlight included prisons, emergency services, social services, and healthcare.

By 1998, the Kennett government had their eye on the Port Macquarie NSW experience of hospital privatisation. They had their foot on the accelerator and appointed private companies to build and operate several public hospitals; Knox, Berwick and La Trobe Valley, as well as the accident and emergency services in Rosebud. They made their next focus the building and management of Mildura Public Hospital, which they placed into the hands of private companies. The eventual successful tenderer for this hospital’s management (as separate to the building contract) was Ramsay Health Care. Ramsay’s appointment was initially for a period of 15 years, with various review points and extensions possible, they would operate the newly built hospital of 156 beds.2 Apart from filling the gaps in the government coffers, the Kennett coalition contemplated greater benefits from the public and private partnership model.

The private sector is said to be more flexible in how it can adapt and respond to changing service provision needs, with a greater scope for increased investment. There was no doubt it attracted talented, skilled workforce members and gave them access to a private provider’s network, that could offer or match commercial employment contracts.

Ramsay Health Care’s tenure as operator of the Mildura Base Hospital outlasted both the Kennett coalition and most of the other private and public partnerships developed during their term.

Return of Mildura Base Hospital to public ownership

In 2013, the Napthine Victorian state government acquired back the Mildura Hospital buildings from their private owner, the MTAA Super fund.3 In September 2020, after a lengthy political campaign, Mildura Base Hospital management returned to Victorian state government hands under the Andrews government.4

Providing outpatient care to obstetric and gynaecology patients: the Mildura Model

When I arrived in Mildura in 2008, many outpatient services in rural and regional Victoria were already provided for in the private setting, following closure of hospital outpatient services. This allowed cost sharing between federal and state governments and the consumers. This was the model in which I started my Australian consultant career. All antenatal and gynaecology fertility patients were seen in the private rooms, but the births were public and provided at Mildura Hospital. All the obstetricians were visiting medical officers (VMOs) on an on-call roster for the hospital. In some cases the midwives worked across both settings but were largely employeed by the public hospital sector.

Subsequent to my arrival, Ramsay did build their own private rooms and more patients were seen in a bulk billing setting, but the majority of care was still in the private sector.

The Mildura Model worked well from a continuity of care point of view. The care was shared between the medical and midwifery practitioners.5. This was possible in a significant number of cases, even in the hospital setting. The roster was 1:4 nights and weekends on call. We offered easy access or referral to holistic antenatal and postnatal care. As required, we saw all our booked postnatal women in the rooms at six weeks. The practice was geographically close to the hospital which helped to improve safety. This service has become more fragmented as more doctors have moved in to work in the Mildura Hospital clinic, and care has spread across public and private sites.

However, the workload was significant, and the lines could become blurred particularly regarding birth attendants, as the antenatal care was essentially private. We had ultrasound in the rooms, but no CTG monitoring or induction of labour equipment, so we had to outsource some antenatal investigation to the hospital ward. We used handheld patient records and Genie printouts, but access to a contemporaneous healthcare record was sometimes an issue.

Access to the private clinic for the postnatal patients was a particular benefit, allowing appropriate birth debriefing, assessment of physical recovery, access to breastfeeding assistance and contraception care as an ongoing element of holistic pregnancy care.

The Warrnambool Model

South West Healthcare Warrnambool has always remained a publicly funded state government healthcare service. When I moved to Warrnambool, the outpatient care model comprised of a Medicare Billing Service (MBS) and a public outpatient antenatal clinic for all antenatal women intending to birth in Warrnambool. It ran on a rotating basis by the local VMOs and one staff specialist. Most gynaecology patients were seen in private and booked as required to the public or private hospitals.

After five years in that model, I moved to a full-time staff specialist role and significantly increased access to MBS and public gynaecology. There was no private obstetrics in Mildura when I lived there, and none in Warrnambool to date.

Many issues are easier to manage in the Warrnambool setting, with shared access to digital health records and access to all antenatal services including the radiology department on site. There is less medical continuity of care, in that most women end up seeing multiple different consultants and trainees. This is offset by the fact that midwives from the maternity ward work in the clinic as well, improving continuity, and we offer a continuous midwifery program as well. There are a limited number of practitioners involved in the Continuity Midwife Program and it is not available to all women who would like to be cared for in this model.

Caring for the region

When I worked in Mildura, care for the outlying communities was provided in some cases via the private practice, with various clinics attended in surrounding towns, across three states; Berri, Robinvale and Broken Hill. Women and families also travelled long distances from these places to be seen in Mildura.

This model also exists in Warrnambool, with clinics in Hamilton, and operating lists in various regional hospitals allowing care closer to home. There is access to maternity services provided by GP obstetricians in several local areas. Camperdown Hospital is a rural hospital managed by South West Health Care Warrnambool, allowing GP obstetrics, and gynaecology operating in the public setting.

The future of regional and rural obstetric and gynaecological services

I prefer the mixed funding model that I currently work in, although acknowledge that some of the benefits of continuity my patients and I experienced both in Mildura, and in my private practice in Warrnambool, are less apparent in this setting.

A public obstetric and gynaecology service provides accessibility and equity of care, and good opportunity for training junior doctors, midwives and registrars. Clinical governance is an inherent component of the public system. It is an ongoing challenge and debate for the public system to provide funding and resources to facilitate better continuity of care.

Private obstetric and gynaecology services are much valued by communities to provide choice, particularly for continuity of care. Private gynaecology services in particular are able to provide good service for women’s healthcare and make up for the shortfalls in access in the public system due to limited funding. Much of our care in gynaecology can be provided in the clinic setting and private clinics can be an important part of care provision to the community.

In summary, I feel that the best option is a combination of public and private services, particularly in regional and rural areas. In recruiting future regional specialists, the option of a combination of public and/or private work is beneficial and sought after. A private practice has the rewards of autonomy as a practitioner, both in terms of medical skills and the close patient relationships that become established. A public appointment for equitable care provision and teaching is also attractive. The system works best for patients, communities and specialists when these options work together to provide the best care and outcomes.

 

References

  1. Dixon R, Mahmood M. The Victorian Economy in the 1989/90-1992/93 Recession. Australasian Journal of Regional Studies. 2008;14(2):155-166.
  2. Martin B. Victoria, Privatisations and colocations. Available from: www.documents.uow.edu.au/~bmartin/dissent/documents/health/victoria.html
  3. Cook H. Napthine government to buy back Mildura Base Hospital. The Canberra Times. 2013. Available from: www.canberratimes.com.au/story/6153706/napthine-government-to-buy-back-mildura-base-hospital/
  4. Duckett S. Public-private hospital partnerships are risky business. The Grattan Institute. 2013. Available from: www.grattan.edu.au/news/public-private-hospital-partnerships-are-risky-business/
  5. Pregnancy Care Guidelines. Australian Government Department Available from: www.health.gov.au/resources/pregnancy-care-guidelines/part-b-core-practices-in-pregnancy-care/providing-pregnancy-care-services

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