Paul Smith, the political editor at Australian Doctor magazine, has been tracking the progress of health reform, and reckons those of us bemoaning the slow progress at COAG this week might be overlooking some of the reform action that’s been going on in the background.
“You could say that it’s rubbish. Two years on from the election of a Federal Government quick to boast of its reformist agenda, and still nothing much has happened in health apart from a lot of talk and the expression of some fine intentions.
Millions have been spent on months of public consultations and expert advisory committees and taskforces and national road-shows — but still no detailed announcement on what our elected leaders are going to do about it all.
Prime Minister Kevin Rudd came out of the Council of Australian Governments (COAG) meeting on Monday night talking about needing to ensure that we get reform right, which makes you think this could go on for a very long time — a politically convenient long time beyond the next Federal Election.
Opposition health spokesman Peter Dutton described the Prime Minister as “Australia’s favourite health bureaucrat”, more obsessed with minutiae of process than outcomes.
Following the COAG meeting, we still don’t know if the government will become the single funder of all primary care services or what is going to happen in the funding and management of public hospitals. The pledge that, if public hospitals fail to show improvements, there would be a referendum and (subject to the electorate’s wishes) a federal takeover, looks like what it always was – just empty grand-standing.
Mr Rudd’s government, to be fair, has always stressed that its detailed policy response to the health reform recommendations will be made early next year (although the language suggests a shift to the middle of next year).
What was missing on Monday night was any sense that federal and state governments are united on the general direction reform is going to take. Without consensus, most of the large-scale ambitions for Ending the Blame Game between state and federal governments – an end to the cost-shifting and the waste and dysfunction and mismanagement that it generates – are lost.
Perhaps the challenge was always going to be too great when the push for constitutional change often reduces to a win-or-lose game where politicians fight to retain the one thing that justifies their existence – their power. But there are other problems. While the high-level political machinations on what should be done continue, the obsession with consultation seems to have put on hold other lower-level reforms many believe the system needs.
It didn’t attract much media scrutiny, certainly not as much as it deserved but the National Health and Hospitals Reform Commission made an urgent plea, among all its other recommendations, for major investment in sub-acute services – the “missing link” of the Australian health system.
In an area such as mental health this would be a revolution of sorts – a stop to the revolving door nightmare faced by patients who are continually battling one crisis after another because there are so few options once they are out of the acute ward.
And what about access to medical services in aged care facilities? That problem (I’d say scandal) has not temporarily disappeared while Mr Rudd waits to get the reform process right. May even offer some partial relief to the overload in public hospitals – from ED to ICU.
The government could even roll out trials of voluntary patient enrolment for GP practices to see if the system really does what its advocates say – improve continuity of care for those with complex chronic conditions.
Instead, when it champions its policy successes thus far, the government will be able to refer to the increased investment in public hospitals to reduce waiting times for elective surgery and, in terms of primary care, the roll-out of GP super clinics — even though at the minute there are only two actually up and running.
Apart from Federal Health Minister Ms Nicola Roxon, I don’t think I’ve spoken to anyone convinced these super clinics constitute a major advance in primary health care delivery.
The government hasn’t exactly been inactive in health. But the action has been taking place elsewhere.
There have been the attempts to means-test private health insurance, “reform” pathology and Medicare funding, and it is about to embark on a move to cut back on PBS spending. It’s true that slashing rebates for cataract surgery has become hideously protracted – even though the amount of money saved relative to Australian health spending is miniscule. Cutbacks to the Medicare pathology budget have been far more effective – hence the squeals from the pathology industry – but more or less out of the public’s sight. And we will have to see what happens on PBS spending (particularly to the cash that goes to pharmacists). The media reports in the Australian Financial Review suggest that Ms Roxon wants to find $1.2 billion in savings.
These attempts to claw back money point to the real problems facing the government and its health reform commitments – it’s the lack of hard cash.
There was a lot of talk about the stars being in alignment for health reform after the 2007 election. It was like watching what happened in the UK a decade ago when suddenly there was a political commitment to sort out the NHS. There are many similarities between the ideas being peddled in the UK and the ideas now being peddled here because many of the problems are the same.
But there is an obvious difference. Tony Blair’s government was at the time able to increase funding for the NHS and its structural upheavals by $A99 billion a year.
But on the back of the global financial crisis, Australia is buried in massive public debts. The price tag on the NHHRC blueprint is between $2.8 billion and $5.7 billion a year, plus one-off capital costs of up to $7.5 billion, with promised savings to be generated in the future. When Labor came to power that deal would have looked expensive but not outside its scope. But now?
The commentators and politicians have been bemoaning the lack of action on health reform following the COAG meeting. But they may not be looking closely enough. “Reform” of a kind is happening – it’s those cutbacks to cataract funding, the attempts to rein in pathology spending, to control the Medicare bill, to save on the PBS …
None of this means that some of the wanted reforms will not come. But the attempted cutbacks we see now are the best indicator of the financial realities on which any wanted reform depends.”
• This article was originally published online by Australian Doctor yesterday