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Anyone else bored with the hospital masquerading as health debate?

The timing of Tony Abbott’s health policy pitch – just a few days after the release of the Marmot Review in England – couldn’t have been more telling.

While other countries are moving towards a more enlightened debate about health, we are stuck with a focus on hospitals, and whether power is best vested in doctors or administrators. I’ve written more about these issues in this piece just published at The Drum on the ABC website.

Yesterday I spoke with, or exchanged emails with several leading advocates of health reform to hear their views on the Abbott plan for locally run hospital boards. Below are the transcripts of our conversations and emails:

Professor Ian Hickie, director of the Brain and Mind Research Institute:

More local decision-making around the constellation and delivery of clinical services is good so long as it’s within a national framework with local delivery. Everyone is very frustrated to the extent with which central Soviet-style planning doesn’t work, as per NSW’s highly centralised services. Many people feel management has become clinically ill informed.

But there are two dangers. You will have hospitals competing with each other again. Every hospital will want to do liver transplants etc, and the better-resourced areas will always do better. Decisions then come to reflect the wealth and political influence and history of the hospital. You get into this problem of very strong local characters, including local doctors, not working in the wider community interest but in very local interest.

The other problem is the hospitals focus. We are already an over hospitalised population with a lack of community and subacute infrastructure.  Hospitals are traditionally disconnected from the much wider range of health-related activities. You need cooperation rather than competition between hospitals.

Hospital boards are a back to the 1950s idea. But it will gain traction because the current alternative is a highly Soviet-style, centralised system that is not responsive to the community or consumers.

As health policy it’s dumb, but Abbott is smart about the politics.

If we move towards regional primary health care organisations, as the Rudd Government seems to be, we are in danger of getting something that is just as doctor-centric as hospitals. That wouldn’t be good either. Primary care doesn’t need to be run by GPs or divisions.

I’m totally in favour of regional organisation of services with hospital, primary care and other services networked at a regional level. How they are funded and supported is a different issue.

It’s very hard to have these discussions because we have no idea of what the shape of health reform will be. We don’t know what the government is planning. If we really had one level of government running financing, and a national framework for regional service delivery, then it could work. But if it’s just added to the current dog’s breakfast, then regional fund holding could be disastrous.

We are really stuck because the Rudd Government has not having declared their intention. Nobody wants to discuss what is specifically wrong with the current situation, the inequities, the maldistribution, the poor productivity, the poor management of chronic disease, and the chronic failure to deal with Indigenous health, mental health and child health.

We’re not discussing what’s wrong that we want to fix. It’s been very unclear. We need the Government to say which problems they seek to fix. Is it inequity, reliance on out of pocket expenses; is it better use of the national investment? What are their priorities? Are they just political, like surgical waiting lists?

That’s where the discourse is lost; the Government can’t say what it principally wants to fix and therefore what its priorities are. We’re none the wiser about what the Federal Government thinks are the major problems and therefore what are the major solutions. We haven’t had leadership from Rudd or Roxon and that’s why we end up with these diversions. Tony Abbott is pitching to the doctors, the AMA.

There is much more sophisticated debate overseas.  Ours is haphazard or short term political.

***

Dr Sue Page, Northern Rivers Department of Rural Health:

It’s really critical that these be regional health boards not be hospital boards. We want to be move away from the hospital being the focus of health attention. And what about all the towns that don’t have hospitals?

The next question for me hooks onto local capacity. We want to have local decision making but that requires local capacity. The smaller and more disadvantaged the community the more critical their input is likely to be to effect change, but the less likely it is that they will have people with financial and governance training. If you look at the history of the AMS model for instance, many boards have had repetitive cycles of dysfunction.

What I think would work best then is for regional health boards to have a partnership type model whereby people with bureaucratic expertise mix in partnership with local clinicians and representatives from the local community in equal numbers.

Under the old model, boards were drawn from local business who sometimes didn’t have the ability to play in the big field so they often ended up dabbling at the edges and avoiding difficult decisions. From this, in NSW we swung to the other extreme by having a ceo – a sole senior bureaucrat – given all the autonomy – and a community and clinical advisory board without enough power to influence their decisions.

So we need a partnership model of clinical, community and bureaucratic governance. Every board should have a minimum of two people representing the most health-disadvantaged group in its area, while clinicians should come from a variety of disciplines and not just from within hospitals. No decision making body, no matter who’s on it, can function unless really well supported with data so the board needs ready access to transparent information.

We then need to ensure health funding is weighted to reflect need rather than hype. I have never heard a community forum argue for access to elective surgery waiting lists. What the community asks for is better access to things like mother and children’s services, mental health, addiction services and adolescent health.

I would stop counting hospital waiting lists. We count them because we can, but it’s a crap measure and it influences where money is spent. If you believe in health equity, you’d report on closing the gap between your top and bottom quintile instead.

If I could rule the world, I would put health as a federal responsibility with a central bucket of money allocated to geographical regions on a per capita basis with weighting for disadvantage. This stops the cost shifting debacle and encourages better collaboration. But it needs community responsive regional governance, supported by meaningful data, with some rules set to help all regions perform to their best advantage.

***

Carol Bennett, Consumers Health Forum:

Tony Abbott’s plan won’t fix entrenched problems in the health system but will create further ownership by the medical profession in the system. We’d like to see the system evolve to a more shared, multidisciplinary, collaborative model of care. He refers specifically to doctors and nurses, but doesn’t recongise that there are other players in the health system that go beyond those two professional groups.

The NHHRC report underlined the need to put consumers at the centre of the health system. This plan does nothing to advance that objective. It just further entrenches the system we have and will further inflate the kinds of problems we already have.

I don’t see local boards being representative of the community or necessarily able to advance the community’s agenda just because they’re local boards. Consumers have said they don’t care what structure we put into place, what they’re concerned about is the outcomes. We won’t get good outcomes if we just continue to fund more hospital beds and more doctors. We need to invest in community care so people don’t need to end up needing more hospital beds.

One of the major impediments to health reform in this country is that every time you discuss health reform, you’re talking about hospitals and doctors. We’re not talking about health. We’re very entrenched in that culture of illness and how you treat things. It’s partly because of the silo funding. But I also think it’s driven by groups like the AMA which have a strong vested interest in maintaining the status quo.

It’s just such a shame because in the health sector, most groups agree on what needs to be done, but then we have these discussions and it always comes back to more beds or more doctors.

We need to be having community discussions to ensure that people get across the literacy that those of us in the health sector have access to. So people start to understand there’s a different way of doing things. It isn’t just about pouring more money into the acute system, that we’re going to need to change the way we look at providing health in the community.

Health system reform is never a quick fix; there’s enormous vested interest and complex systems involved. You can’t just wave a magic wand and fix it.

**
Associate Professor Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity:

Re community engagement
·        In general a ‘good thing’, but note that it needs to be broad if it is to bring forward the needs/views of the community as a whole (and especially those most in need) rather than an influential group.

·        It also needs very good governance, and some very specific accountabilities.

·        It needs to be at the right level of aggregation. There is room for community engagement in specific services (migrant health), facilities (specific health centres or hospitals) and networks of services. Taking hospital boards in isolation is to miss much of the picture.

·        Engagement takes many forms. Decision making avoids tokenism, but the scope needs to be carefully defined. How does it relate to clinical governance, the management of networks of services?

·        There may be a danger of politicising health services at a local level – cf the experience with some Indigenous health services (and I suspect hospital boards in the past).

Re hospitals focus
·        I agree this is too narrow, and that community based services are increasingly important

·        One option is to have a board overseeing all local services for a population – community health, hospitals, multi-purpose centres. This at least encourages a more comprehensive approach. Cf the scope of Boards of NSW Area Health Services, in the days when they  were a more sensible size. Note the similarity to the current government’s ideas about primary health care organisations…

·        However services are increasingly networked, horizontally (sharing diabetes care between community health, hospital, general practice) and vertically. You need to ensure that boards don’t get unnecessarily in the way of these necessary processes.

·        The hospital board issue sometimes sounds like a proxy for the struggle between administration and medicine for control of health services. Here be dragons! Including a danger of demonising the administrators and under-estimating the complexities of planning and operating modern health services.

**

Fiona Armstrong, freelance journalist and policy analyst:

Like many politicians when referring to health care, Abbott is hitting on hospitals as the key issue in health. While it is vital we have improvements in the functioning of our public hospitals, their deficiencies have more to do with inadequate funding than failed governance models.

Overall the governance of health care is a problem, but this is much bigger than the running of individual hospitals. It is certainly true that there is a disconnect between clinicians and administrators of hospitals however, but it is far from clear that the creation of local hospital boards would fix that problem.

However like most politicians, Abbott understands that for cut through messages to the electorate, ‘fixing our hospitals’ is a simple rallying cry, well understood (and exploited) by both the major parties.

But political messaging can only get you so far. At some point you have to try to and solve the problem. The current government does understand the complexity of the problem, which is not to say they intend to fix it – it’s tricky – but they have had a clear and considered look at the problem and Roxon, of all the health ministers in the last decade, has a solid understanding of the issues.

However Abbott’s plan seems to lack the understanding that it is not just the governance of health and hospitals that is at fault (although it should of course be improved) but also the funding formula. Creating another layer of bureaucracy should only happen if it going to improve accountability and effectiveness (of resource allocation/performance/care). Hospital boards in isolation will only serve to further isolate the acute system from the rest of the health services with which it is vital to integrate.

And unless local boards have funding that is based on health care need, local boards will always be handicapped in terms of what they can achieve i.e. they will never be given enough money from the Commonwealth or states through a conventional bargaining method – so the value of localisation can only be realised if it is accompanied by a needs based funding formula that is driven by data that extends beyond historical patterns of usage.

Abbott’s boards would be “government appointed” so it is unlikely that such a process will empower the community, be representative of the diversity of the demographic, or be truly accountable to the citizens. The aims of establishing local boards in this proposal looks more like an opportunity to shift the blame elsewhere when things go wrong, as they so frequently do in hospitals.

There are some who are using this argument to say that local boards and RHOs (regional health organisations) won’t work because of the example of NSW area health services – however this is a poor comparison given that the control of NSW area health services has always remained in Sydney, not at the regional level.

And unless regional governance means regional solutions supported by funding that reflects regional health needs, any proposal to “localise” is meaningless. Appointing regional health boards who are empowered to commission all the necessary health services for their local population however offers an opportunity to create more accountable, locally responsive bodies that would be able to integrate the range of health services in the region more effectively, allocate resources more effectively, use funds more efficiently, and ensure greater transparency in health care financing, as progress would be measured in outcomes, not throughput and improved health outcomes would result.

But this is far from what Abbott seems to have in mind.”

**

Ben Harris-Roxas, health equity expert, University NSW:

There are several issues with local hospital boards but the main two are:

  • there’s no clear role for community health, because even though they’re critical for managing complex conditions, post-hospital care and integration with general practice they don’t fit neatly within hospital structures; and
  • who will make up hospital boards themselves? Meaningful community representation on boards is difficult, and it will be important to make sure that more than current or former hospital clinicians are on them. They could potentially reduce accountability rather than enhancing it.

Surely we’ve reached a stage where we should be thinking about areas and populations, not hospital buildings.

***

There are more posts coming on these and related issues….

Comments 2

  1. Pathologist says:

    I believe that everyone in health has a very clear conflict of interest…..healthcare workers, administrators, patients and their carers. I am unsure why any particular group would be fair minded or altruistic about the allocation of resources. Healthcare is becoming very expensive…..we need to decide how much (as a country) we are willing to spend on universal care and prevention. There is very clearly a waste of money in the current public system and it would be easy to fix it….but then why don’t we increase the drinking age, the price of alcohol and cigarettes……why do we spend millions of dollars immunising people against the flu in spring etc?

  2. Doctor Whom says:

    The fact that Abbott was a health minister with public commitment to “doing nothing” to the health system means its hard to take him seriously on health matters. In addition he appears to be a bit lazy and not very interested in understanding issues in depth.

    The big worry is the current health debate is really designed to fix problems in NSW and QLD.

    Boards managing hospitals? Big deal in Victoria – we’ve had them in one form or another for 30+ years. Sure they are the creatures of the Minister of the day but they work.

    Boards managing Community Health Services? – Big Deal. We’ve had them too since the 70’s. Some members appointed by the minister others elected from their communities. It works.

    Not only is there a problem in couching the health debate in terms of hospitals. Even within those limited terms the debate is narrow and dangerously wrong. We hear frequent calls for more hospital beds. Minsters evaluate funding proposals on “how many new beds can we announce”.

    A big part of the volume in hospitals is day procedure.

    Operations where people are only in the hospital for a few hours or so. This is an area of rapid expansion and demand.

    The need is for more day procedure centre de-coupled from acute /emergency demand and bumping of patients and list. Many day procedure do not even need to be close geographically to high tech tertiary hospitals. Improved day procedure facilities free up beds in hospitals and reduce waiting lists.

    But politicians (and frighteningly Canberra Health bureaucrats) do not understand day procedures or modern medicine. They still think in terms of beds and male doctors in white coats (or the slightly more modern green or blue scrubs).

    Improved aged care (and primary care for chronic illness) will free up hospitals. A huge volume of A&E attendances, and also hospital admissions, are due to falls in the elderly. Falls prevention programs in the community do work.

    Increasing numbers of dying people are transfered to hospital beds for weeks just to die. People are transfered for home and from nursing homes. Hospital really can do nothing for these people that couldn’t be done better elsewhere. They block beds and die in a industrial sterile environment. Improved facilities for dying in palliative care residential buildings and at home would be better for everyone concerned.

    Regional Health Organisations (RHO) with a high level responsibility for at least 500,000 – 1,000,000 persons (less in rural areas) with a capacity to plan and allocate broad funding (but not run the services) over all health, public, promotion, early intervention, primary care, GPs, research, hospitals, aged care, mental health, palliative care are needed to be able to strike a balance.

    RHOs can have useful consumer patient input, (keeping in mind most consumers don’t want to be consulted or be activists they just want a good enough and timely service) improve health literacy and push money to where real prevention and early intervention will actually and demonstrably work to decrease hospital demand and improve health. (as an aside I have great concerns that much of the prevention support and push is rhetorical and not evidence based – not to mentioned riddled with more conflict of interest than an orthopod on a Fiji Cruise.)

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