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Crises bring opportunities for health reform (perhaps): Stephen Leeder

Stephen Leeder, Professor of Public Health at the University of Sydney, analyses the opportunities for health reform:

We have entered the Year of the Ox.  Might it morph into the Year of the Oxymoron, where contradictory combinations of words – tough love, compassionate conservatism, decentralised governance – will reach epidemic levels, affecting health policy?

Health care is now as complicated, wondrous and bewildering as the night sky, and so political that the notion of policy – an agreement amongst all interested parties that we will spend the health dollar in this way and not that – is under serious threat.

With several federal health policy planning groups providing reports soon about hospitals, general practice and primary care, prevention and Indigenous health care, we will know by year’s end whether policy – beyond oxymoronic statements – is still a possibility.

The interim report of the National Health and Hospitals Reform Commission, to be fanfared at the National Press Club on February 16th, will give us a clue.

Please note, the opportunity for moving beyond oxymoronic endorsement of the status quo in health policy may have rarely been better.

Now, in the US also, reform of the health care system is more feasible than for decades.  With tumbling economic fortunes, the automotive industry, for one, is showing less enthusiasm for maintaining employer funded health insurance, creating a space for the US to consider ways of securing basic health insurance, like our Medicare, that is universal in reach, covering the tens of millions of Americans without cover.

In Australia, the decision to fund infrastructure renewal and development as part of the federal government’s response to the economic downturn has already created opportunities for the health system.

Several billion dollars have been committed for infrastructure development in health. Reports are due shortly from the major groups charged with developing a broad agenda for reform in health care. The time for implementing reform may hardly be better.

Investment in a reformed publicly funded health care system will benefit both short and long term economic recovery. This investment could start with substantial upgrading of public hospitals.  In the short term also, the structure of general practice can be reorganised to meet the needs of increasing numbers of people with serious and continuing illnesses.

Looking further ahead, investment in research and prevention infrastructure will help Australia develop solutions to long term health problems such as mental disorders, dementia and cancer. The directions for reform are clear.

First, although Australian health care is outstanding by international standards, we hope that the commissions will detect accurately the hot spots in need of reform. Cumbersome and tired bureaucracies have institutionalised themselves and developed their own metalanguage of restraint and risk aversion.

Using layers of regulation and performance indicator reports, they have insulated themselves against all discernible risks and changes, especially those likely to lead to ministerial embarrassment.  They have cut off community input.  A disgruntled community and frustrated professional workforce are the result. Innovation, which always carries the risk of failure, has been stifled.

Second, for a decade a conservative government invested in the private health care system at the expense of the public.  The public system struggled to meet urgent day to day demands. Waiting times in understaffed and overcrowded emergency departments and unpaid debtors’ bills are merely the public face of this distress.  No capacity remained to adapt to the changing profile and burden of disease from the serious and acute to the serious but chronic and long-lasting, from the needs of a younger community to those of an ageing population.

Our commitment to humane care for all has sagged at the knees partly because the system has lacked the recurrent funds and the infrastructure to respond.  New managerial arrangements are needed and the future financial contributions to health care from states and Commonwealth – an ancient and bloody battleground that does nothing for health – rectified.

In fitting out and staffing our public hospitals and facilities to take care of those with chronic illness, we would set the stage for a future health care system that is humane and technically capable.  Funding to provide infrastructure for integrated primary care in the community would improve the efficacy of our response to chronic disease.

Third, comparable investment in prevention and an appropriate infrastructure to support it where none currently exists at present there are no major national institutes of prevention in Australia at present – would enable future generations of Australians to enjoy better health.

Prevention must address effectively the health problems of our lifestyle.  We can encourage and enable individual responsibility and support social structural modifications including affordability of healthy foods over unhealthy ones, better public transport options and urban design.

Additionally, investment in research gives us a better understanding of the nature of mental and physical illness, which may have long term pay-offs. Short term, we can stimulate the economy by building and equipping new laboratories and constructing and financing new research facilities for basic, clinical and population based research. The staff and ideas are there and now we need more infrastructures.

This moment of crisis gives us an opportunity to consider proposals for health reform that have both short and long term pay offs for better health, as well as helping to heal our economy.

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