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After years of reform recommendations and agreements, brave leadership is required

As National Cabinet meets this Friday to consider health reform proposals, an overview of recent history is instructive.

Croakey columnist Adjunct Associate Professor Lesley Russell, who has been investigating the lessons from national health reform agreements, reports that “brave leadership” is required.


Lesley Russell writes:

Given media reports that state leaders will use the meeting of National Cabinet on Friday to push Prime Minister Anthony Albanese for Medicare reforms to improve affordable access to primary care services, it is instructive to look at what the National Health Reform Agreements 2020-2025 contain.

These agreements between the federal and the state and territory governments are about much more than the financing of public hospitals – although that is where most of the money goes. They also include goals and initiatives addressing primary care and prevention.

The current agreements were announced by then Prime Minister Scott Morrison on 29 May 2020 and came into effect on 1 July 2020. It is worth noting that these negotiations and sign-offs took place at the height of the first wave of the COVID-19 pandemic and after the establishment by Morrison of the National Cabinet.

First, a brief history of the National Health Reform Agreement (NHRA).

In 2008, the Rudd Government set up the National Health and Hospitals Reform Commission (NHHRC) to conduct a comprehensive review of Australia’s health system (read more in this recent Croakey article).

In August 2011 the Council of Australian Governments (COAG) agreed to a new National Health Reform Agreement setting out the shared intentions of the Commonwealth and State and Territory Governments to work in partnership to improve health outcomes for all Australians and ensure the sustainability of the Australian health system.

The new Agreement, which came into effect from 1 July 2012, included a range of initiatives and reforms to Australia’s general practice and primary healthcare system, including Medicare Locals, GP Super Clinics and infrastructure grants, the practice nurse incentive, after hours arrangements, and additional GP and allied health professional training.

This agreement was updated from 1 July 2017, and updated again from 1 July 2020, in both instances following sign off by COAG.

There is some earlier history of these funding agreements in an article by Charles Maskell-Knight.

The most recent NHRA Addendum (these vary somewhat for each State and Territory; a consolidated agreement is here) agreed to four strategic principles to guide health system reforms:

  • Improving efficiency and ensuring financial sustainability
  • Delivering safe, high-quality care in the right place at the right time
  • Prioritising prevention and helping people manage their health across their lifetime
  • Driving best practice and performance using data and research.

The Addendum states that “the long term health reforms under the NHRA will support better coordinated care in the community, focus on prevention and keeping people out of hospital” and that to this end the Commonwealth and the States will work in partnership to “improve the provision of GP and primary health care services, including Aboriginal and Torres Strait Islander community controlled health organisations, and the effective integration of health services at a local and national level” and to ”improve care coordination for people with chronic and complex needs.”

The National Health Reform Agreement Long Term Reforms Roadmap was endorsed by all Australian Health Ministers at the Health Ministers’ Meeting on 17 September 2021.

This identifies further the key areas for reform:

  • Nationally cohesive Health Technology Assessment
  • Paying for value and outcomes
  • Joint planning and funding at a local level
  • Empowering people through health literacy
  • Prevention and wellbeing
  • Enhanced health data
  • Interfaces between health, disability and aged care system.

The roadmap outlines actions, deliverables and timeframes, and the potential impact of COVID-19 for these key areas of reform.

Under the responsibilities outlined in the 2020-2025 Addendum, the Commonwealth and the States will be jointly responsible for, among a long list, “identifying rural and remote areas where there is limited access to health and related services with a view to developing new models of care to address equity of access and improve outcomes.” And the Commonwealth would be responsible for “working with each State and with PHNs on system-wide policy and State-wide planning for GP and primary healthcare.”

There are lots more words and phrases and commitments we would all likely agree on.

To support implementation of the reforms, the Commonwealth provided $100 million for a Health Innovation Fund for trials that support health prevention and the better use of health data. This funding is managed separately through Project Agreements under the Intergovernmental Agreement on Federal Financial Relations. These are listed here.

Taken at face value, it is an exciting possibility that the Commonwealth and States and Territories have agreed to work on healthcare reforms on these important issues. Dare I say that many, even those who work in this space, will be surprised at the extent of these cross-government agreements.

Certainly we might wonder why – in the current climate of concerns around general practice, primary care, and the need for better care coordination – there has not been more focus on the returns on the investments made over a period that now spans five years.

Much of the blame can be sheeted home to the Morrison Government and former Health Minister Greg Hunt; they never showed any interest in meaningful healthcare reform. Essentially they were in the business of providing a little money ($100 million is not a lot of money to be split among eight states and territories over a period of four years) for a few pilot programs, the results of which we are unlikely to ever see.

At least some states have been working in this space. See, for example, this media release about what New South Wales and Victoria are doing with GP-partnered services (although I do not know how this work is funded).

There are clearly some instances where initiatives have been very slow to roll out, and many others where information is simply not publicly available.

The previous (2017 – 2020) NHRA Addendum included separately signed bilateral agreements on coordinated care reforms. These varied somewhat from state to state, but all included a focus on developing a Primary Healthcare Minimum Data Set and a role for Primary Health Networks. At least some of the agreements (for example, that with NSW), included the collection and sharing of data from Health Care Homes.

I have been unable to find any public references to the interjurisdictional working group that these agreements indicated would “identify policy opportunities for coordinated care” for COAG in 2019. Yet Schedule C of the current Addendum states that it is “building on the activities set out in the 2017 Bilateral Agreements on Coordinated Care and incorporating them into relevant long-term health reforms (Schedule C).”

The work towards developing a National Primary Healthcare Minimum Data Set (the importance of such a data set was outlined in 2019 in an issues brief from the Deeble Institute and in an article in Croakey Health Media) is happening, but very slowly.

The Australian Institute of Health and Welfare received funding in the 2018-2019 Federal Budget to begin this work; the AIHW website provides some indication of progress on developing and implementing this data set.

A separate Primary Mental Health Care Minimum Data Set is up and running. This is operated by a Department of Health contractor.

As an aside, it’s interesting to note that in June 2021 the Morrison Government funded seven Primary Healthcare Research Data Infrastructure grants from the Medical Research Future Fund. The extent of interaction or overlap with the National Primary Healthcare Minimum Data Set is not clear.

The most recent NHRA Addendum states that the National Health Information Agreement would be reviewed and revised by April 2021, but the AIHW website states that the current agreement dates from 2013.

An external review is scheduled to be undertaken at the midpoint of the current Addendum, to be completed by December 2023.

It seems so terribly wasteful of resources – funding, research and clinical efforts, data, and (especially) established partnerships – that so little has been made of this work by either federal or state governments.

Its importance has been lost in the argy-bargy over the level of the federal contribution to public hospitals (it’s many years since this was a 50:50 partnership with the States and Territories) and concerns that additional funding provided to offset the impact of the COVID-19 pandemic on public hospitals ceased on 30 December 2022.

It has presumably not been helped by the changes wrought when COAG was replaced by the National Cabinet and the COAG Health Council, which was where most of this partnership work was hammered out, was replaced by the Health Ministers’ Meeting

Even a casual reading of the recommendations of the NHHRC report serves to remind us how much we know about what is needed to reform Medicare and the healthcare system generally to improve health outcomes for all Australians.

In the 14 years since this report, the pile of reports from task forces, commissions, committees and inquiries has only grown.

It’s time to mine the archives, lay out a road map for actions to address the recommendations, and then fund and implement them. All that’s missing is brave leadership.


Also read: Remember the National Health and Hospitals Reform Commission? Here’s a pointed refresher

 

 

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