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A change in the weather: Ley’s legacy, and a to-do list for her successor

Ruth Armstrong writes:

For many working in health, the question of the week is who will be the next Federal Minister (in case you’ve been off the grid, Sussan Ley resigned her portfolio of Health, Aged Care and Sport last Friday, after the ongoing controversy about her travelling expenses was deemed to be too much of a diversion from the Government’s agenda for the New Year).

Ley had held the ministry since the end of 2014, taking over from Peter Dutton at a time when the proposal to introduce proposed co-payments for General Practice consultations was causing widespread industry and community disquiet.

With the issue of who will be her replacement still hanging in the fetid January air, Croakey put out the call to some policy informants and stakeholders, for their perspectives on Sussan Ley’s legacy, and what loose ends our next Minister for Health will need to pick up.

With most people still emerging from their summer funk, not everyone we asked was available for comment, but those who have, have given the incoming Minister plenty to go on with!

The winds of change are coming. May they bring refreshment, rather than storms.

Dr Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney

For what actions or decisions will Ley be remembered?

Sadly, Sussan Ley will be remembered primarily as the Minister for Incomplete Actions.

She was unable to do anything to address the Medicare rebate freeze and its consequences; she failed to complete a deal over budget cuts to the pathology sector; and there has been no action on the changes recommended by the MBS Review.

Nothing significant has been done to ensure tax payers get better value for private health insurance (either directly through their premiums or indirectly through the rebate); the energy and enthusiasm that once supported the Health Care Homes proposal has dissipated as a consequence of poor consultation and an unsustainable funding mechanism; and mental health reforms are languishing.

Key issues such as obesity, climate change, and closing the gap on health and healthcare disparities, especially for Indigenous Australians, were rarely, if ever, raised by Ley – remarkable for a portfolio charged with overseeing the physical and mental health and wellbeing of the Australian population and the financial sustainability of the healthcare budget.

What are the risks associated with Ley’s departure from her portfolio?

It takes time and effort to master the Health portfolio and understand the needs and stances of the wide range of stakeholders, so time will be lost as a newcomer gets up to speed – this as the 2017-18 budget is being prepared and with a raft of decisions awaiting ministerial approval and leadership.

To some extent these risks could be ameliorated by appointing someone who has held a junior ministry in health. Let’s hope there is no temptation to reappoint either Abbott or Dutton – that would be disastrous.

What are the major issues left on the table for Ley’s successor?

All of the issues mentioned above.

In particular, the Health Care Homes trial is supposed to be up and running by July; that looks less and less likely.

The 5th Mental Health Plan has been out for consultation and there is general agreement that it needs a lot more heft to be a useful and strategic plan for mental health reforms and services over the next 5 years.  The next iteration is due in February, although there has been a push to delay this to address the large number of concerns.

In the meantime, the Primary Health Networks must struggle to commission mental health services with constrained funds and little guidance, and to integrate services for those with severe and complex mental illness as the National Disability Insurance Scheme is rolled out.

The work of the MBS Review must continue at an increased pace, and with prompt attention to the implementation of its recommendations if Australia is to ever have an MBS that matches the medical needs of the 21st century.

The gaps between what Medicare pays and what doctors and allied health professionals charge continues to increase, giving rise to increasing out-of-pocket costs and undermining the universality of service are needed.

The maldistribution of healthcare professionals is a continuing problem for non-metropolitan areas.

Real healthcare reforms in services and financing require that federal and state and territory governments work together cooperatively. Most of the major National Partnership Agreements in health and related portfolios have now lapsed.

What lessons can Ley’s successor learn from her tenure?

It is important to listen to and consult with all stakeholders – not just the AMA, the Pharmacy Guild and the Private Health Insurers.

Doing policy well is hard work, and implementing it effectively is even harder.  But more reports, committees or advisory groups, with delayed responses and actions will not make these tasks any easier.

The Department of Health must develop the capacity and/or the willingness to develop and oversee policy, modelling, implementation, evaluation and expansion of initial small-scale efforts.

Any predictions for who will be next?

What is needed is someone with enthusiasm for the task at hand, who will genuinely listen to and make the effort to understand the needs and concerns of all stakeholders, who recognises that investments in health and healthcare deliver returns in productivity and social equity.

It needs to be someone who can forcibly make the case to those who control the budget and who can work across portfolios and levels of government to better address population health needs.  Does such a person exist?

Michael Moore, CEO, Public Health Association of Australia

From my perspective the outstanding contribution to Australia’s health by outgoing Minister Sussan Ley was her commitment to improving the lives of people suffering from Hepatitis C. At a time when the government was crying poor and looking for ways to save money, the Minister was able to get agreement for an investment of around a billion dollars over five years to tackle this disease. There is no doubt that this was no easy task within the Cabinet, the Party Room or the Party.

With over 700 deaths attributable to Hep C every year in Australia, Sussan Ley was prepared to commit funds to subsidise cures that were costing individuals up to $100,000 annually. She did not question the level of their condition or how they contracted Hep C – just moved to make the money available.

From 1 March 2016 multiple drug combinations were listed on the PBS and therefore available to the entire population.  These included Sofosbuvir with ledipasvir (Harvoni); Sofosbuvir (Sovaldi); Daclatasvir (Daklinza); and Ribavirin (Ibavyr).

The significance of her contribution to tackling a disease that spreads particularly amongst one of the most vulnerable populations cannot be understated.

Dr Michael Gannon, President, Australian Medical Association

For what actions or decisions will Ley be remembered?

She will be remembered for scrapping the Government’s ill-conceived co-payment plans, and for implementing the reviews of the MBS, private health insurance, and the prostheses list.

Getting rid of the co-payment proposals was universally welcomed. There were some nervous moments early on with with the MBS Review, when it was portrayed as a cost-cutting exercise with little or no clinical input.

The Review process seems to be going more smoothly now, with more clinician involvement, but the final product will determine how history judges it.

The introduction of the Health Care Home trial is promising, but needs greater funding if it is to work properly.

Unfortunately, much of Ms Ley’s time as Minister has been overshadowed by the ongoing freeze of Medicare patient rebates.

What risks are associated with Ley’s departure from the health portfolio?

The risks of a new Minister taking time to learn the complexities of the portfolio are a loss of continuity in reform processes, and the possibility that the many reviews will stall.

There is a lot of unfinished business – the freeze, the pathology rents situation, Commonwealth-State relations, to name a few.

What are the major issues left on the table for Ley’s successor?

The Medicare freeze tops the list. It must be lifted, preferably in the May Budget. The reviews, the Health Care Home trial, public hospital funding, mental health, Indigenous health, and major public health issues such as combating obesity- all these things need urgent attention.

What lessons can her successor learn from Ley’s tenure?

The big lesson is to engage with the health professions. Genuine consultation is all-important. Ms Ley made a much better effort than her predecessor.

The other important thing is to always look at health policy as an investment, not a cost.

Alison Verhoeven, CEO Australian Healthcare and Hospitals Association

For what actions or decisions will Ley be remembered?

Sussan Ley took on the health portfolio at a difficult time: the Abbott government had seriously misjudged how deeply Australians value universal health care, with a slash and burn approach to hospital funding and proposed co-payments in primary care.

Restoring relationships with the AMA, introducing a series of policy reviews and strengthening primary care were first items on the agenda when Sussan Ley was appointed Health Minister and things initially looked promising .

But by the time of the 2016 election, almost no changes had been delivered, although some positive reforms such as health care homes were in development; and it was clear that the Turnbull government had not gained a greater appreciation of the value Australians place on a strong, well-funded public health sector.

There have been too many policies made on the run, sometimes to appease powerful private business operators; too many favoured groups allowed to navel-gaze and review the policy settings in which their businesses operate; and too many delayed funding decisions followed by short-term and inadequate funding (the pre-Christmas cuts to public dental care announced a fortnight before funding ran out are an example).

And critically there has been a lack of overarching strategic vision for health policy, nor any real attempt to align political decisions with the values of the electorate.

What risks are associated with Ley’s departure from the health portfolio?

The greatest risk is that Australians will be offered more of the same – a scatter gun approach to health policy, weakening of the public sector and promotion of privatisation of health services to save government money, notwithstanding the impact on out of pocket costs, affordability and equity.

The positive health care home reforms initiated by Sussan Ley will continue, but there are substantial risks associated with these, including the funding of the program, its design, and supporting infrastructure such as e-health and data.

The new health minister must contemplate this as the 2017-18 budget is formulated. This reform must deliver positive results for governments, health services and consumers, or it will go the way of previous primary care reform attempts.

What are the major issues left on the table for Ley’s successor?

In addition to primary care reforms, private health insurance reforms are pressing (neither the government via its subsidy or consumers are realising value for money); and an agreement with the states and territories on public hospital funding beyond 2020 requires urgent attention.

Public dental funding is woeful and there is almost no preventive health agenda – both of which have long term consequences for individual health and wellbeing, as well as health expenditure.

What lessons can her successor learn from Ley’s tenure?

The best leaders are genuinely consultative and collaborative, drawing on robust evidence available to them to make decisions; and ensuring these are coherent with an overarching vision and strategy, and aligned with stakeholder and electorate values.  A health minister who approaches the role with this in mind may encounter fewer of the hard lessons learned by many previous health ministers.

Any predictions for who will be next?

I don’t know who will be appointed next health minister, but I hope in making his decision, the Prime Minister selects a person who will bring strong negotiation skills, a consultative manner, and a willingness to work with all in the health sector. Health policy can make or break a government and has enormous impact on the well-being of Australians: we need a star performer!

*UPDATED*

Leanne Wells, CEO, Consumers Health Forum of Australia

For what actions or decisions will Sussan Ley be remembered?

Sussan Ley commenced a number of reviews with the intent of reforming major areas of health. Outcomes of those reviews and any reforms which flow from them will determine how she is judged. There was, and remains, no overarching vision of what the health system should look like.

While welcoming reviews into critical parts of the system that need change and improvement, CHF was always concerned that there were too many reviews occurring simultaneously and had some doubt about how they fitted together.  We called consistently for an integrated policy agenda and attention to evidence based implementation.

Highlights…

Picking up some of reforms suggested by the Australian National Audit Office audit of the Fifth Pharmacy Agreement, and ensuring greater transparency for the Sixth Community Pharmacy Agreement was a highlight of Sussan Ley’s tenure, as was the establishment of the independent review of pharmacy regulation and remuneration that is currently underway.

Establishing the Primary Health Care Advisory Group and stewardship of the Health Care Homes trials to provide better primary care to people with complex and chronic needs is a very much overdue reform, which could be a game changer.

Starting to empower and use Primary Health Networks as regional commissioners and stewards of more responsive local health systems, by devolving funding at scale for local planning and service procurement, was welcome.

Lowlights…

These included extending the freeze on Medicare rebates – especially on GP payments – and moves to abolish the bulk billing incentives for pathology and diagnostic imaging.

After commencing with such promise, the slow pace of the MBS review in weeding out low value care and redundant items, and poor patient engagement in the process, is another lowlight.  The review has been running for nearly 2 years, and there’s very little to show for it in terms of reducing waste associated with low value interventions.

CHF remains a staunch advocate of the need for fundamental reform of Private Health insurance, rather than tweaking the current model. This is another area where Sussan Ley appeared committed to getting a better deal for patients but where the use of a myriad of committees risks dilution of the the appetite for change.

What are the risks associated with Ley’s departure from her portfolio?

The reviews will continue, potentially with more consultation to meet the new Minister’s needs. This will delay implementation of change.  It depends on the appetite for risk of her successor, and whether or not the government wants to continue a reform agenda.

What are the major issues left on the table for Ley’s successor?

Her successor needs to develop a vision, and pull the various reviews together into a coherent whole.

Private health insurance clearly still needs a lot of work if it is deliver value for the individuals who use and the taxpayer who partly funds it.

We need a greater focus on integrated care in the health policy agenda. Health care homes need to be more than just an experiment.  This model of care needs to be tested, refined and implemented at scale and should be truly integrated in nature. Integration should include not only of medical care but ‘social prescribing’ and evidence-based self-management programs.

The increasing out of pocket costs for consumers across the health system need to be addressed- which relates to Medicare rebate levels and private health insurance.

Prevention has been ignored and this needs to be addressed.

We don’t want to see Primary Health Networks subject to the change and churn experienced by the forerunner divisions of general practice and Medicare Locals.  Australia will benefit from this form of regional structure provided the PHNs have the right clinical and community leadership and levels of funding.  They should be allowed to mature, get on with the job but be held fully accountable through a robust performance framework.

What lessons can her successor learn from Ley’s tenure?

Be clear about why you are reviewing something and don’t consult unless you are interested in what those consulted might tell you. Also be prepared to be transparent about the outcomes of the consultations.

Despite the rhetoric of the system being there for patient and the community there has been little genuine effort to move to a consumer-centered system and little effort put into ensuring consumers were supported to develop as leaders along with their clinical colleagues in order to be systemically and strategically involved in co-designing the reforms.

The 2016 federal election showed that people value access to the healthcare that Medicare brings, and want to see it maintained and improved.

 

 

 

 

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