A deluge of questions for Rudd at the Press Club

Further to the previous post, the questions for Rudd on health reform are pouring in from Croakey contributors. Here are some more:

Associate Prof Gawaine Powell Davies, UNSW Research Centre for Primary Health Care and Equity:
1. Will primary health care be brought into the same system as hospitals, to promote better integration between these levels of care?
2. Can the items in case mix funding include post acute and community care (and therefore be a whole ‘episode of care’), to avoid cost shifting between hospitals and community based care?
3. How will networks of hospitals (e.g. for Emergency and very high level care) continue?
4. How will the new system avoid ‘provider capture’ where providers organise services in ways which suit them rather than the public.

Professor John Wakerman, Centre for Remote Health:
If the press reports are correct about a federal funding/ regional health authority implementation model, I would be interested to ask:
1. How will regions be defined & will they take onto account the heterogeneity & variations in population size of rural and remote regions?
2. How will the government ensure optimal coordination & integration of primary health care & hospital services?
3. How will the proposed scheme ensure equitable resource allocation to rural and remote areas?

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Dr Lesley Russell, Menzies Centre for Health Policy:
1. Where is mental health in all this?
2. Where is dental health in all this?
3. How will this new system move from rewarding providers for activity to rewarding them for improved health outcomes?

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David Crosbie, Mental Health Council of Australia:
The MHCA is likely to welcome any hospital reform that makes the current hospital system more transparent and accountable.  However, hospitals are not islands in the health service system.  In the area of mental health, we know that over 40% of people currently occupying acute mental health beds in hospitals would not be there if community based sub acute care and other options were available.  We also know that Emergency Departments turn away more than two thirds of people who seek help for their mental health disorder.  Fixing hospitals is very important.  Fixing the systems that feed into hospitals and leave people marooned with no other options is also critical.  The NHHRC identified hospitals, primary health care, preventative health, dental care and mental health as the five key areas requiring reform, and this included 12 recommendations (over 10%) related specifically to mental health.  We look forward to further working with the government for reforms in these critical areas.

Our questions would be:
1.    If hospitals are to become more effective and efficient, they will need to have alternative options not only for the frequent fliers on the Emergency Department merry go round, but also for people with a mental illness who have nowhere else to go.  How is this hospital reform going to create the community treatment options so sorely missing in area like mental illness.
2.    If we are really concerned about putting patients at the centre of the health system, are we going to monitor actual health outcomes and will this include basic measures like suicides within one month of discharge from an acute mental health bed?

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Robert Wells, Director Menzies Centre for Health Policy, ANU:
1: What is fiscal impact if states accept your proposals? If there is estimated net additional cost to Cwlth, how much, and why, given this is supposed to be a more efficient system?
2. What is timetable for implementation;  what immediate benefits will there be for patients?
3. Will you proceed if only some states accept? If not what precisely is your next step?

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Sydney psychiatrist Professor Alan Rosen:

1. What does KR intend to do about  mental health service reform?
Specifically:
a)will his government  provide a single  funding source and a mechanism to ensure integrated commissioning of all of public, private  and non-government mental health services on a regional basis, at  arm’s length from service providers?

b) How will his government build up & protect mental health service  budgets from being raided by general health administrations,  considering that mental health constitutes such a high proportion  of  the disease burden but only gets such a small proportion of health   funding?

c} what mechanisms will KR put in place to contain the blow-out and  geographic inequities in private medical  and allied professional
fee-for service payments, as they affect mental health service delivery, and will his government provide indirect payment incentives  to shape the more rational distribution and cost-effective focus of  these services?

d) will his government provide a National Mental Health Commission to  provide a clearing-house of evidence-based practices, arriving at a  more accountable goal-driven national mental health service reform  agenda, and then monitor the quality and equitable distribution of  more evidence-based mental health services, reporting to governments  independently of service providers?

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Indigenous health policy expert, NT:

Q: Structural and progamatic issues continue to burden Aboriginal health. For example multiple progamming funding streams and duplicative administrative arrangements. The recent Cooperative Research Centre for Aboriginal Health report report confirmed this as did the NHHRC report. What new arrangements are the government going to put in place to reform the funding, performance monitoring and planning arrangements in Aboriginal health to deliver the necessary efficiencies to lift outcomes in this vital area?

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Ben Harris- Roxas, University NSW:
1. What’s in your policy that will specifically reduce health inequalities?
2. You’ve said you’re committed to evidence-based policy; what evidence is this policy based on?
3. You’ve described this as a “better hospitals” policy; what are you going to do for community health services? Mental health teams, child and family nurses, etc
4. Where’s prevention in this policy?

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Dr Paul Dugdale, ANU:
1. Does this require a redirection of GST revenue? If so, is that redirection dependant on the Senate?
2. Will the regional health service funding authority be administered under the Financial Management Act, ie be fully accountable to the Commonwealth Government for its financial decisions?
3. Will the states continue to be responsible for the planning and operation of the regional public hospital networks?
4. Will the Commonwealth require regional hospital networks?
5. Will Canberra and Queanbeyan hospitals be in the same region? If answers”possibly”, ask how.

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Professor Peter Brooks, Melbourne:

1. How will he ensure that hospitals do become more productive?
2. What will be the benchmarking data to compare hospitals?
3. Will hospital/ doctor clinical outcomes be publically available – as for example cardiac surgery in NY state?

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Dr Paul Harnett, Dr Sue Harnett (Sydney):
(1) Many believe the most pressing problems are in primary care, and keeping people OUT of hospital. What is being done about primary care, as opposed to acute inpatient care?

(2) What will happen to funding of hospital outpatient services, and things like chemotherapy drugs – the great majority of which is funded/cost-shifted by charging medicare and/or the PBS for these services? Will this still be possible under these new arrangements or will these services be in effect cut by being non-billsble for outpatients but not included in the funds allocated to regional health authorities?
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Dr Andrew White, paediatrician, James Cook University:

1. What will his plans do for Aboriginal people from communities in SA and WA close to the NT border who have been made to travel to far off Adelaide or Perth for dialysis treatment rather than to Alice Springs which although also a long way from home is much closer, and where there is
contact with family members etc.

2. One reason for hospitalization or delayed discharge of children from hospital is lack of community services able to support children (and their families) with disabilities – physical, psychological or behavioral. How would his plans improve this situation?

3. Regional hospitals are currently often the poor cousins of  hospitals in the capital cities,and new services or innovations in delivery are not allowed because of dictates from the capital city health departments. Would involvement from Canberra actually allow services to be innovative and
improve or just make it even harder than it is today?

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Dr Catriona Bonfiglioli, Univesity of Technology, Sydney:
• Is the PM working from a model which has been shown to be successful anywhere?

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Justine Caines, Homebirth Australia:
Maternity reform was the first cab off the rank. It is the largest volume area of health and reform has been long overdue, with nearly 40 inquiries since 1985. The reform to enable midwives to access Medicare has the capacity to improve outcomes and reduce costs. Can you explain how this reform will actually be implemented when at this stage there is no mechanism to grant midwives visiting access to hospitals and alarmingly they will only be able to admit a patient as a private patient?

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Professor Peter McIntyre, Sydney:

1. How would infrastructure and strategic developments (eg new Childrens Hospital in Melbourne, proposal to unite tertiary paediatric services in NSW as NSW Kids,  new buildings in general which are outside the scope of routine maintenance etc) be identified and supported under this new arrangement?  Clinical research could also potentially fall foul of such a structure if not seen as “core business” – is the NHS the sort of model which would apply with regional governance but central policy and funding?

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Professor Ric Day, University NSW:

1. When will we move to generic names of drugs being the prominent and preferred way of prescribing and labelling drugs to stem the toll from the confusion around multiple brands of the one drug?
2. Why is the government not committed to investing in the evaluation of the outcome of the huge (8billion pa) expenditure on medicines purchased by the PBS by establishing a national data linkage capability linking PBS and MBS and other data bases using de-identified individual records as is done effectively in Scandanavian and Canandian states?

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Professor Ian Olver, Cancer Council Australia:

1. When is he going to respond to the Preventive Health Task Force recommendations?  (particularly as he has committed to reduce smoking prevalence to 9% by 2020 and yet has said nothing about the major measure of increasing tax on tobacco and has announced no strategy to counter obesity)

2. How is he going to address the issues of the current difficulty of accessing data (from the states) and linking data to be able to measure the outcomes of health reform?

3. What is his plan for the current rural and regional inequities in health care particularly the National Health and Hospital’s Reform Commissions recommendations for increases for patients travel assistance?

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Gordon Gregory, National Rural Health Alliance:

1. How will smaller hospitals without economies of scale fare under an extended DRG system?
2. What will the relationship be between regional hospitals and regional PHOs?
3. How will GP-led Divisions become health-oriented PHOs?

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Margaret Brown, Health Consumers Rural and Remote Australia:

From a Rural and Remote Community perspective I would like to be reassured that consumers are kept informed, consulted, and are really aware of what the announcement means for them and their local health care facilities.  Too many changes have occurred in the past and the mat has just been swept from under them so to speak. Communities have a right to be included in any decision making process, and not as a  “token gesture” either.

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Professor Gab Kovacs, Melbourne:

One of the big problems in hospitals is retention of staff. How about thinking laterally with something novel like putting money into child care within hospital precincts to retain female medical/nursing/ancillary staff?

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Dr Michael Vagg, Victoria:

With the National Pain Summit to be held next week, will there be provision made within public hospitals for multidisciplinary outpatient services for sufferers of chronic pain?

Victorian Hospital specialists have had an EBA agreement since 2006 that 20% of their paid hospital time is supposed to be devoted to teaching and administration and none of the hospitals have implemented it yet as they are concerned that it will cripple service provision. Does the Government propose to fund dedicated teaching and administration time for public hospital doctors, who are currently expected to teach increasing numbers of medical students and postgraduate trainees without pay in addition to their clinical workload?

Why does the Government think Superclinics are a good idea when similar types of clinics have failed to work as planned in the UK, where the average cost per patient encounter at a Polyclinic is as much as 3 times higher than a traditional GP practice, and GPs are campaigning against them as an election issue ? What is wrong with the simple idea of making it easier and more cost effective for GPs to run their practices and employ multidisciplinary teams in existing practices?
ref’ http://www.medicalnewstoday.com/articles/179319.php
http://www.guardian.co.uk/society/2008/jun/05/nhs.health

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Margo Saunders, public health policy consultant, Canberra:

Michael Marmot [expert on health inequalities and Chair of the WHO’s Commission on Social Determinants of Health] decided early on in his medical training that medicine and surgery were just failed prevention. .  … Marmot remembers thinking, “If we could do something about prevention, we could empty the hospital wards.”
[- ‘What has social injustice to do with medicine?’ – Fiona Godlee, editor, BMJ http://www.bmj.com/cgi/content/full/340/feb11_2/c842]

Of course there will always be a need for medical services.  But, according to the National Health & Hospitals Reform Commission and Preventative Health Taskforce, modifiable risk factors are responsible for about one-third of Australia’s total burden of disease, and around 70 percent of the health budget is devoted to dealing with preventable diseases and conditions.  Two percent or less of the health budget is committed to prevention.

Question: What plans does the Government have to change the focus from illness to wellness – to invest more in building the proverbial ‘fences at the top of the cliff’ rather than putting the bulk of resources into the ‘ambulances at the bottom’?

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Ray Bange, Governance and EMS (emergency medical services) policy consultant:

Given that healthcare should begin with the patient and not at the hospital or clinic door, what has the new health policy done about recognising the vital role of out-of-hospital emergency medical services (EMS) and the sustainability and registration of Australia’s most trusted professionals – the paramedics?

Will EMS be the recipient of a stream of national funding or be left out of the health care equation once again?

Why does EMS currently not qualify for Medicare style benefits when many of the interventions performed by paramedics would receive a benefit if performed by a registered practitioner with a provider number? Will this situation change under the new national health care policy?

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Professor Mark Harris, Executive Director, Centre for Primary Health Care and Equity, University NSW:

1. If hospital care is to be funded on a per-patient basis, how will care over time be funded (eg looking after a complex patient on an outpatient basis)?  Will there be enrolment of patients needing long term care?

2.How will public health and health promotion services be funded (as they don’t provide care to individual patients)?

3. What will be done to better integrate care between hospital and primary health care?  How will services that bridge this be funded – like hospital in the home, aged care and rehabilitation etc?

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Dr David Atkinson, WA:

1. The prime Minister has talked about ‘local control’ being better for hospitals.  Does this principle also apply to non-hospital services? How does he envisage ‘local’ coordination of hospital and non-hospital health services and would regional planning forums be a good place to start?

2. Ensuring a single funder for hospital services will help reduce cost shifting, however much of the cost shifting occurs between in-hospital and out-of-hospital care. Wouldn’t a process moving towards regional control of health budgets work to better reduce cost shifting (the Kimberley would volunteer as a pilot site!)

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Dr Peter Parry, psychiatrist, Adelaide:
1. In the USA there has been overdiagnosis of serious psychiatric diagnoses like bipolar disorder with overmedicating in very young children.  One reason for this is health insurers paying doctors if a serious diagnosis is given but not paying if the “diagnosis” is “family relationship problem” etc – the practice is called “diagnostic upcoding” in the medical literature, plus health insurers favouring pay for medication over non-drug therapy.  Australia has been relatively immune from this because Medicare and public mental health services have not stipulated diagnosis but clinical need for interventions and funding of non-drug therapies has been generally adequate.  However, problems of diagnostic upcoding may be emerging with Autistic spectrum disorder in child mental health and major depression in adult mental health because of Medicare changes – is the PM aware of this?
2. The Indian Medical Council have introduced very strict rules on doctors in India banning receipt of gifts, travel, accommodation, and educational grants from pharmaceutical companies.  Furthermore the IMC stipulates all drug trial research be through university departments and not directly with pharmaceutical companies and any research collaboration with pharmaceutical companies requires the doctor and university to have inserted in the contract a clause giving rights to publish all data in the public interest to the doctor.  These rules are more progressive than Australian medical bodies’ rules.  Is the PM or the Health Minister going to discuss the IMC rulings with the AMA and Australian specialist colleges and medical schools?

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Professor David Penington:
1)    Public concern prior to the election was with the quality and safety of public hospital services after disasters in Bundaberg, and then at the Royal North Shore and even in the Road Traffic Unit at the Alfred in Victoria – all hospitals performing well on budgets and patient number indicators.  How will the new model safeguard quality and safety with appropriate clinical governance overseeing the quality of medical services delivered?

2)    Public hospitals have difficulty in meeting the pressure on their beds because of large numbers of older patients unable to be placed elsewhere. This will become far worse with an ageing population.  How will the hospitals or regional boards be able to develop new low-cost Sub-Acute Hospitals providing rehabilitation (comparable to many in the private, not for profit sector) and how will they better relate to enhanced community based support services for the elderly with GPs, community nurses and local pharmacists all playing a part?  If the Regional Boards relate only to acute hospitals, the need for far closer interface between these and primary care will never develop.

3)    How will the necessary close interface between teaching hospitals and Faculties of Medicine and Health Sciences be handled when there are such urgent and pressing needs to meet the demand for more health professional and to develop new training programs for emerging graduates in almost every sector?

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Associate Professor Alexandra Barratt, University of Sydney:

1. How will he ensure that those with health service evaluation skills, such as epidemiologists and health economists, will have a role in evaluating the effectiveness and equity of the services delivered by the new health boards? Clinicians, while good at patient care, do not have these service evaluation skills.

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Dr Sue Page, Northern Rivers Department of Rural Health:
1. If we keep paying for activity, how is that going to change the focus of what we’re trying to do for health care?
2. How are we going to determine what size the regions are? How do we guarantee that each of those regions would have onsite local expertise to be able to make good deciisions and planning?
3. If we are now putting small rural hospitals into competition with the big hospitals across the whole of Australia, how does that work? Are we going to have quarantined funding? Or are we going to have a system whereby the haves continue to have and the have nots continue to miss out? The classic example there is with an NHMRC model, you cant get an NHMRC grant unless you have got one? It’s a flawed logic because it doesn’t allow for capacity raising.
It’s really important to make sure it’s not hospital boards, which will keep the focus on hospitals.

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Professor Stephen Duckett:

Will direct payment to hospitals be equalized by the Grants Commission?  If not, what will be implications for smaller states?  If so, how will we identify how much a hospital will get?

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Professor Glenn Salkeld, Sydney School of Public Health:

Are we paying for activity or for health?