Submission to the Cohealth review

Burden of disease and evidence for community care

Community health organisations are fundamental to an equitable, efficient, and humane health system. Evidence from Victoria demonstrates that integrated, locally accountable primary and community care prevents avoidable emergency department (ED) presentations, reduces potentially preventable hospitalisations, manages multimorbidity more effectively than episodic care, and produces substantial social and economic returns. In 2023–24 an estimated 546,000 ED presentations in Victoria could have been managed in primary and community care settings[i], representing roughly $554 million in avoidable public hospital ED expenditure[ii].

The scale and distribution of chronic disease in Victoria make this a pressing policy problem. Almost half of Victorians (3.2 million people) live with at least one chronic condition—cancer, diabetes, dementia, heart disease and others—and chronic conditions account for approximately $82 billion nationally each year, nearly half of all disease spending[iii] , [iv]. Socioeconomically disadvantaged groups shoulder a disproportionate share of this burden and are more likely to be treated in hospital for health problems that could be managed with preventive care or early disease management [v] , [vi].

Quantitative analyses show that robust primary care and community case management reduce admissions for diabetes, heart failure and other chronic conditions and lower unplanned healthcare use among patients with multimorbidity[vii] , [viii] , [ix] . Infrastructure Victoria’s analysis that diabetes complications produced around 15,400 potentially preventable hospitalisations in 2021–22—consuming approximately 78,300 public hospital bed days—illustrates the avoidable downstream resource use community programs can avert[x] , [xi] [xiv] , [xv].

Similarly, dental disease provokes a large share of preventable admissions. Oral health problems account for roughly one in ten preventable hospitalisations nationally. Prolonged public dental waiting times (statewide averages exceeding a year in recent reports) exacerbate emergency presentations and admissions that community dental services, mostly provided at community health clinics, could prevent. Around 30% of all public dental services are emergency treatments instead of routine maintenance or preventative care[xii] , [xiv]. Dental services at the Cohealth Kensington site are one of the many primary preventative health services that would be lost if this centre closed.

These figures make it particularly concerning that, according to the Australian Bureau of Statistics, 8.8% of Australians delayed seeing a GP due to cost in 2023–24, up from 7% the previous year.[xv] It is of no surprise that it is those experiencing disadvantage that, due to complexity or expense, are more likely to be unable to access primary care services. [xvi] While historically, one may have been able to look at community health care to bridge this gap, a study of 2,548 people done by Infrastructure Victoria in 2024 demonstrates that 45% of eligible Victorians had not used a community health service in the last 5 years, citing long wait times as one of the biggest barriers to access.[xvii]

It is worth taking a moment here to look specifically at mental health. Many community health organisations provide community-based mental health services. Demand for these services is increasing. Victorian Government modelling suggests demand for community-based mental health and wellbeing services will grow significantly over the next decade[xviii]. The Royal Commission into Victoria’s Mental Health System 2021 report acknowledges that:

‘Poverty and disadvantage make it particularly difficult for people to access services. A disproportionate number of people living with mental illness have low incomes and no private health insurance. For many, this makes access to primary care (for example, through a GP) difficult to afford.’ [xxviii]

It recommends that there is a stepped, integrated model of care with the first step being primary care which should thus be the most accessible. Increasingly this is not the case with bulk-billed GPs becoming increasingly difficult to find and community health centres closing their books due to lack of capacityincluding the three Cohealth centres. If primary care is meant to be the cornerstone of community mental health treatment then access to primary care must be expanded. Closing the cohealth clinics would be a step backwards in achieving this best-practice integrated model of care.

Stigma is also recognized as a barrier to seeking treatment for mental health difficulties and alcohol and other drug difficulties. Having a trusting relationship with a primary care provider can help to mitigate this. The Cohealth clinics under threat have been groundbreaking in providing the most effective treatment approach to this population - based on long term trust and familiarity with the staff and the facilities embedded in local communities.

‘Primary care practitioners often form ongoing relationships with individuals and families. These relationships can make it easier for primary care staff to identify people’s emerging mental health needs and monitor their physical and mental health and wellbeing.’[xxviii] Many low income people now rely on bulk-billed ‘superclinics’ which may have many GPs which rotate and thus, not see the same GP repeatedly or build this kind of relationship.

Evidence from Norway and Denmark demonstrates that fragmenting care away from established community health providers produces predictable and measurable harms. The loss of long-term GP relationships—particularly those exceeding ten years—is associated with a 25% increase in mortality. Disrupted continuity of care also leads to a 12–28% rise in acute hospital admissions, alongside a 20– 30% surge in emergency department presentations, most notably after hours. Medication safety deteriorates under fragmented care models, with higher rates of prescribing errors and adverse drug events when patients are forced to see multiple unfamiliar clinicians.xxxi

The benefits of colocation

Numerous Cohealth patients have identified how valuable co-location of services has been. “I can get my leg looked at, my scripts and my medications filled all in the one place”. For patients with mobility difficulties, cognitive challenges and multiple health co-morbidities co-location is invaluable - allowing people to access health and social services together. Locating different health professionals and social support workers together in one primary care facility can lead to more specialised and preventive care for people with chronic conditions.[xix] , [xx]

This includes homeless people who currently use cohealth services. A recent study found that health outcomes for homeless people were significantly better when they are able to access dedicated health centres and specialist GPs [xxi]. Participants and staff welcomed “flexible and tailored approaches to care and related services being available in the same building” - including alcohol and other drugs, mental health, local health and homelessness services. This is the current model at the three community health clinics and is tried, true and effective - particularly given that these centres have established trust and relationships with the service and staff - often over decades. Losing services at these co-located clinics - and potential loss of sites with established relationships (e.g. the Cohealth Collingwood site) will leave many vulnerable people without access to these integrated services that support health and wellbeing.

Structural failures in financing, incentives, governance

Structural failures in financing, incentives, and governance have produced this avoidable load on complex and acute healthcare. First, Medicare and primary care funding are misaligned with contemporary complexity: per‑person Australian Government spending on general practice was $452 in 2023–24— essentially unchanged in real terms since 2015–16—while per‑person public hospital spending rose substantially over the same period [xi]. The Medicare Benefits Schedule still structurally rewards short consultations, limiting capacity for the extended, multidisciplinary encounters now required by patients with multimorbidity such as those using cohealth services. This has been a major contributor to Primary care GP services being seen as financially unsustainable - despite the key role these services provide in maintaining and supporting health. These trends drive people, especially those on low incomes, toward EDs when their conditions have deteriorated.

Second: episodic, marketised substitutes and activity‑centred funding models fragment care. Urgent Care Centres (UCCs) and similar episodic walk‑in models are costly per consult (estimated at ~5 times the per‑consult funding of a GP) and do not provide continuity, preventative care or long‑term disease management—functions central to reducing hospital demand [xvii]. The Australian College of Emergency Medicine makes this very point in a statement published in 2022:

“… emergency departments aren’t, as the myth goes, dangerously overloaded because too many people present who couldn’t see their GP today. There will always be some overlap between primary care and ED regarding management of acute health problems that need timely care. When people come to ED with relatively simple problems, they usually require only simple treatment, and can go home after receiving care. These low acuity presentations do create some extra workload for EDs, especially for departments that see lots of children, but are not the root cause of the problem.

Instead, EDs are dangerously overloaded because they see too many people who simply couldn’t access or afford the care they need in community settings over longer periods of time. Without access to appropriate care, people get sicker, their health deteriorates, and their acute conditions become chronic. Often, they also become socially marginalised. Then, when things get unbearable or unmanageable, and they are suffering immensely, they present to EDs for urgently needed help…By this stage, their health needs are so complex that they require admission to hospital for high-level care. But it doesn’t end here. They are too unwell to go home, and there is simply nowhere for them to go to get the further care they still need. Due to their complex health needs, and the lack of capacity in critically lacking areas of federal responsibility, the NDIS, aged care and mental health services, the patient gets stuck in the ED. The main hospital is full – as are all the neighbouring hospitals – and there are no beds available or staff to care for them. So, they get stuck in the ED. For hours, or sometimes days”

The statement concludes “The worst part is, this could all have been prevented by access to affordable, accessible, integrated primary and community-based care over time” [xxi] .

Additionally, activity‑based funding, competitive tendering and short‑term grants encourage throughput metrics over relational, community‑embedded prevention. This has encouraged the short term treatment of discrete diseases and conditions - a biomedical model of healthcare which has lost touch with the original community health model which focuses on primary, preventative healthcare. Where community health organisations were forced to chase discrete contracts and grants, they lost capacity for long‑term programs, salaried multidisciplinary teams, and the community engagement that historically oriented services toward social determinants of health. Non government organisations like cohealth that are forced to compete for healthcare grants tend to not budget for ongoing organisational and infrastructure costs (Social Ventures Australia, 2024) [xxiii]. This well known and problematised “starvation cycle” of NGO’s has contributed to facilities like the cohealth Collingwood clinic becoming run down.

Community Health Programs within Victoria have been underfunded for decades with particularly harsh cuts occurring under the Kennett government which actually began cutting funding for community health programs. This was also tied to reporting expectations and neoliberal rationalisation and control of healthcare services - and corporatisation of healthcare services. In this context of austerity and funding cuts and increased competition for grants, local services run by community controlled boards merged. This has led increasingly to reliance on appointed and highly paid experts to manage and run health services and their funding streams.

The federal government has loudly promoted its new Bulk-Billing Practice Incentive Program as a fix for the crisis in general practice. But beneath the fanfare, particularly in the community health context, it amounts to a drop in the ocean. The program offers a flat 12.5 per cent incentive payment to clinics that bulk bill all eligible patients for specific services. This payment does not vary by consultation length or complexity. Given the clear evidence discussed above that GP consultations are becoming longer and more complex, driven by rising chronic disease burden, mental health presentations, and multimorbidity, a flat incentive disproportionately favours shorter consultations and does not align with current patterns of clinical demand. The program also re-introduces full reliance on Medicare funding in a context shaped by nearly a decade of rebate stagnation. As RACGP commentary has noted, this creates uncertainty for practices making long-term staffing and service planning decisions [xxviv]. Without indexation reform or incentives linked to complexity and time, the program’s capacity to improve access to comprehensive primary care remains limited.

Governance issues with the cohealth board

Victorian Socialists have heard directly from multiple staff and patients who were dismayed and shocked to find out by text or media that the cohealth board was planning to close the Kensington, Fitzroy and Collingwood clinics.

It is hard to imagine this happening when the three community health centres were run by democratically elected boards. As outlined by Townsend et. al (2012) [xxiv] prior to the formation of cohealth, the organisations that ran the three centres threatened by closure would hold regular meetings with patients and healthworkers. According to Rennis Witham a CEO of Western Region Health centre, which merged to become cohealth in 2014, “Victoria has a history of independent boards of health services that were all accountable to the community”. [xxvi]

When North Yarra merged with Western Region Health and Doutta Galla to become Cohealth in 2014, that democratic model was dismantled. The board became incorporated, community membership was abolished, and decision-making drifted away from those it affected most. The current crisis is a direct outcome of that shift. Today, unelected board members can decide to close clinics, terminate staff and sell off community assets without answering to the people affected (Wheatley, 2025) [xv]

Now staff are exhausted and demoralised - considering options for more reliable and secure work given the uncertainty they face for their jobs. They are still passionate and highly effective in their work but are struggling to provide the healthcare they are trained and skilled in. This is due not only to intermittent and insecure funding for services based on tendered grants but an opaque and unaccountable corporate governance structure which is anathema to the original community health, democratic model.

As former cohealth board member Stephen Alomes has stated: “Cohealth has betrayed dedicated professionals, patients and the communities which created OUR health centres.” [xxx]

The community health centre model continues to be a vital and special part of Victoria’s healthcare system. It recognises the need to provide specialised and holistic care for people living with complex health issues and comorbidities. It operates on a social model of primary and preventative health which, due to its effectiveness and popularity, once had bipartisan support [xxiv]. It still has widespread community support but the community, including the workers, patients and local residents, have not been supported by the Cohealth board. They have also not been supported by the state and federal governments which have underfunded these vital services, as well as community health programs more broadly.

What Victorian Socialists stand for

Historically in Victoria community-controlled centres with elected local boards delivered integrated services and with strong community participation. This system treated healthcare as an essential human right rather than a commodity. Where corporatisation and centralised, unelected boards have taken hold local accountability has been weakened and decisions—clinic closures, service reductions—have harmed patients, demoralised staff, and undermined trust.

This is a travesty. The community health model is not a failed experiment—it is one of the most effective, equitable and socially grounded health systems Australia has ever built. It is a uniquely powerful model that integrates healthcare with social support, prevention and local accountability, and it should be expanded nationally, not allowed to be hollowed out and dismantled.

If we are serious about repairing this damage we must begin from first principles; universal access to healthcare, full and sustained funding for preventive and community services, and democratic control of those services by the communities that rely on them. This means ending a system that allows profit to be extracted from illness and rebuilding a genuinely public health system—free at the point of use, accessible to all, and guaranteed as a human right.

• Establish dedicated, indexed, recurrent public funding for Community Health Organisations (CHOs) Funding must reflect patient complexity, not crude activity metrics. This means moving away from shortterm grants, competitive tendering and throughput targets, and toward long-term, block funding that enables CHOs to plan, retain staff and invest in infrastructure. Indexation must keep pace with wages, growth in demand for services and the rising burden of chronic disease. Funding formulas should explicitly account for multimorbidity, mental health need, disability, homelessness and social disadvantage. This model must not remain confined to Victoria: governments should commit to the expansion of community health centres into other states and territories, establishing publicly funded, community-controlled clinics as a core pillar of primary care nationwide.
• Make democratic governance a condition of public funding
  Any organisation receiving public community health funding must be accountable to the communities it serves. This requires restoring democratic governance structures, including open annual general meetings, paid community membership, and elected board representation for patients, workers and local residents. Unelected, corporatised boards should not have the power to dismantle essential services without accountability.
• Support salaried, permanent multidisciplinary teams
  Community health works best when care is delivered by stable, salaried teams—not fragmented fee-forservice providers. Funding must support permanent roles for GPs, nurses, allied health, pharmacists, Aboriginal health workers, mental health clinicians and AOD specialists working together under one roof. Governments must fund permanent, salaried positions rather than forcing services to rely on short-term contracts tied to insecure grants. This model enables continuity of care, and preventive, relationshipbased practice that episodic models cannot deliver. Secure employment improves retention, continuity of care, and worker wellbeing—directly benefiting patients and communities.
• Preserve and expand the integrated, colocation-based care model utilised at the cohealth clinics.
  Co-location is not an optional add-on; it is essential infrastructure for people with complex needs. An integrated model that allows for multidisciplinary care at a single site will greatly improve patient outcomes. The most vulnerable and unwell patients are the least likely to be able to manage and attend numerous appointments spread across a number of practices and locations. Furthermore, having a multidisciplinary service model allows for a high level of continuity of care. Rather than narrowing the care provided at cohealth, all services that exist within cohealth should be retained across all locations and further funding should be provided to ensure a full multidisciplinary team at all sites.
• Expand and properly fund Medicare and public hospitals
  Medicare funding must be expanded across general practice, mental health, allied health, oral health and other essential services, alongside increased investment in public hospitals. Hospital funding must grow in parallel—but never as a substitute for strong, accessible primary and community care. The goal is to reduce avoidable hospital demand by strengthening care upstream, not to normalise ED overcrowding or crisis-driven care.
• End the reliance on episodic substitutes like Urgent Care Centres
  Funding should be redirected away from costly, stand-alone walk-in clinics that provide neither continuity nor prevention, and toward comprehensive community-based primary care. Any urgent care model must be embedded within, and accountable to, existing community health services—not imposed as a parallel system that fragments care and drains resources.

The closure of community health clinics is not an accident—it is the predictable outcome of a system that allows profit and austerity to override need. We stand for rebuilding a genuinely public, universal health system: free at the point of use, accessible to all, and controlled by the communities it exists to serve.

References

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